In January 1985, United States Agency for International Development invited March of Dimes to attend a meeting of professionals, which led to the establishment of International Coalition for Promotion of Breast-feeding – ICPBF. It is the leading non-governmental organization (NGO) in the world that specializes in the promotion of breast-feeding practices, as well as dealing with broader policy issues of breast-feeding from a national advocacy perspective.

The coalition began program activities in 1987. Over the years, ICPBF developed programs that helped implement breast-feeding policies, launched national IEC campaigns, and trained nurses, doctors, and community leaders in the importance of breast-feeding and appropriate weaning practices. Over the last 13 years, ICPBF has worked in over 12 countries with great success. One of our most successful breast-feeding interventions took place in Rwanda where 90% of infants are now exclusively breast-fed!

Haiti is the western one-third of the island of Hispaniola in the Caribbean. It is surrounded by the Dominican Republic to its east, the Atlantic Ocean to its North, and the Caribbean Sea to its West and South. Haiti has a total area of 27 750 sq km, slightly. Its climate is tropical and semiarid, with a mostly rough and mountainous terrain. The population estimate as of 1998 is 7.25 million people, with a 32% urban population. 95% are of African descent. (2)

The population growth rate is 2%, or expanding by approximately 200 000 more persons every year. The birth rate is 35.3/1000, death rate 11.9/1000, infant mortality rate 131/100 live births, total fertility rate 4.7 children born/woman, life expectancy at birth a total of 56.6 years (55 years for men, and 58 for women). Haiti ranks 34^th in the world for under five mortality rate (134/1000). The total population is young, with 3.4 million people being under the age of 18. The official language of Haiti is French, but Creole is widely spoken. The religious breakdown is 80% Roman Catholic and 16% Protestant, with almost all having faith in traditional beliefs.(3)

Haiti is the poorest country in the Western Hemisphere, with a Gross National Product of $230.(4) It ranks high along with some of Africa’s poorest countries. Haiti’s economy is fragile, unemployment high, the environment is degraded, infrastructure and health conditions are poor, and agricultural productivity and educational levels are low.

The economic embargo imposed on Haiti from 1991-1994 following the fall of democratically elected President Jean Bertrand Aristide had a devastating impact on an already precarious economy. From 1992-1994, GDP growth fell by more than 30%. However Aristide’s successor Rene Preval, has helped push the county into positive growth. He has reduced government spending, cut the budget deficit and pushed an economic reform package through Parliament. Preval’s commitment to reform Haiti has gained approval from the International Monetary Fund.(5)

International donors currently finance more than 60% of Haiti’s budget. Efforts have focused on creating short-term employment, rebuilding the justice system (including disbanding the army and establishing a national police force), restructuring government, repairing the country’s infrastructure and assisting with elections.

The total health expenditure per capita in Haiti is unknown, but it has been estimated at $27 for 1996-1997, representing about 8% of the GDP. The private sector provides more than 50% of the total, users contribute 30% of expenditures, while the non-governmental organizations (NGOs) probably contribute 20%. Donor agencies and the government make up the rest, with the government contributing approximately 10% of the total health expenditures.(6)

Public spending in health is 10.7% of total public spending, and represents 1% of the GDP. Local level and territorial distribution data are unavailable. Public spending per inhabitant was $3.9 in 1995, a figure that is 63% of the 1990 figure.(7)

The government University Hospital in Port-au-Prince absorbs 17% of the public health spending, although this percentage has decreased over the last three years. 28% is spent on other public health hospitals, 3% on pharmaceuticals and 4%-5% on equipment. Almost 70% of the public health budget is spent paying wages. A user fee system is used in both the public and private sectors, although the amounts collected are not sufficient to cover all the costs of services. Haiti has 49 hospitals and 61 centers with beds, for a total of 6473 hospital beds. They are unevenly distributed throughout the country, with a 52% concentration of beds in the metropolitan area. A third of the institutions belong to the public sector.(8)

There is no referral system in place among different suppliers and different levels of care. Patients go directly to one level or the other depending on convenience and their reasons for seeking out the system. The primary level care works well, but it only covers 60% of the population, leaving 40% with no access to health care. (9)

Most women in urban areas live near health centers: 79%-98% in Port-au-Prince, and 62%-87% in other cities. The percentages in the rural areas are not as high. Most do not see health professionals due to transportation problems. (10)

About 70% of women are attended by traditional midwifes during delivery. Trained personnel attend only 46%, while 80% had their most recent child at home. There are large differences between rural and urban areas: 50% of women in Port-au-Prince usually go to a hospital, compared with only 31% in other urban areas, and 9% in rural areas.(11)

Haiti has a strong and widespread traditional belief and practice system. Some of these traditional beliefs hinder breast–feeding practices. For example, in the first month of life, in addition to breast-milk, 79% of babies receive liquids (other than water) and solids.(12) Furthermore, many babies are given liquids to "clear their stomachs" before they receive milk and newborns are purged to remove impurities and prevent colic.(13) Another common belief is that "the milk of nursing mothers is vulnerable to displacement, improper mingling and permanent irreversible spoiling.(14) " For example, " impetigo is believed to be caused by milk which is too thick. Chronic or acute maternal stress can cause breast milk to become too thin, move upward to the mother’s head, and result in maternal headaches, postpartum depression, and infant diarrhea. If a lactating woman becomes upset, her breast milk may become spoiled and could poison the child."(15) Also, some mothers do not breast–feed because it is believed "that breast milk can cause intestinal parasites or diarrhea."(16) In addition, women who feel that they are malnourished do not breast-feed their children.(17)

"Haitian mothers, also, have very specific beliefs regarding appropriate meal times and diarrhea. Some mothers think that breast-feeding should be discouraged at night."(18) Regarding diarrhea, 38% of mothers think that a child should not be breast-fed when the child is suffering from it.(19) "Mothers who think breast-feeding should be discontinued have a variety of reasons for their belief. Some think that the mother might be causing the diarrhea by transmitting the problem in the breast milk. Others think milk itself is the problem because it is considered a hot food."(20) In the Haitian belief system diseases are categorized as either "hot or "cold."(21) "Diarrhea is considered to be a "hot" condition and therefore requires cold foods to achieve a balance. Examples of "cold" foods are avocados, mangoes, bananas and orange juice."(22)

Another problem regarding breast-feeding in Haiti is that "bottle feeding is regarded as something appropriate and good."(23) "Use of bottle feeding in urban areas of Haiti is almost universal, whereas in rural areas is less common."(24) In addition, "bottle feeding is also used as a pacifier in Haitian culture where a quiet child is considered a good child."(25)

Furthermore, "women working outside the home tend to breast-feed less and bottle feed more than unemployed women. However, women working in the home (usually engaged in sales of produce) also tend to breast-fed less than unemployed women."(26)

ICPBF will attempt to change the above-mentioned misconceptions through the various interventions presented in this project.

In January 1985, United States Agency for International Development invited March of Dimes to attend a meeting of professionals, which led to the establishment of International Coalition for Promotion of Breast-feeding – ICPBF. It is the leading non-governmental organization (NGO) in the world that specializes in the promotion of breast-feeding practices, as well as dealing with broader policy issues of breast-feeding from a national advocacy perspective.

The coalition began program activities in 1987. Over the years, ICPBF developed programs that helped implement breast-feeding policies, launched national IEC campaigns, and trained nurses, doctors, and community leaders in the importance of breast-feeding and appropriate weaning practices. Over the last 13 years, ICPBF has worked in over 12 countries with great success. One of our most successful breast-feeding interventions took place in Rwanda where 90% of infants are now exclusively breast-fed!

In 1996, ICPBF underwent an overall program evaluation. This evaluation confirmed that the organization’s performance was satisfactory. The evaluation also revealed that increased funding for ICPBF brought bigger staff and higher client numbers.

ICPBF’s management structure in Haiti is as follows. There is one Country Director, who used to be the Executive Director for March of Dimes. Under her, we have three Program Officers, and a Finance Director. One media consultant, training consultant, messenger, cleaner, driver, two secretaries and two student interns (on a six month rotating basis) will be hired (see Annex 1a, b).

Currently Haiti has an infant mortality rate (IMR) of 131/1000 live births. The two principal causes of this high IMR are diarrhea (37 percent) and undernutrition (32 percent). Factors that contribute to the high percentages of children dying from diarrhea and undernutrition are cultural beliefs and practices contrary to exclusive breast-feeding, and inadequate potable water supplies and sanitation.(27) ICPBF intends to focus on changing the damaging cultural practices and promoting exclusive breast-feeding for children in the first 4 months of life in an attempt to break the cycle of diarrhea and malnutrition, leading to a decrease in infant mortality.

This project aims to increase the number of exclusively breast-fed children age 0-3 months in Haiti from 3% to 25%, with the ultimate goal of reducing the infant mortality rate of children under five from 131/1000 to 100/1000 (approximate ~ 20% reduction).

The objectives of this project are:

• encourage Haiti to adopt a working national policy on exclusive breast-feeding by Dec. 31, 2001
• change attitudes and cultural beliefs, and increase the knowledge of the Haitian population in regards to the benefits of exclusive breast-feeding during the first three months of life by 20% in 5 years
• convert all public hospitals to baby-friendly status (following the 10 steps to successful breast-feeding) by 2003
• train all physicians and nurses in the public health sector, as well as community health workers and school teachers, in the promotion of exclusive breast-feeding
• establish a sustainable mechanism for monitoring and evaluating breast-feeding activities in the public health sector within the first two years of the project

UNICEF estimates that only three percent of babies 0-3 months old are exclusively breast-fed. A higher number of infants are breast-fed in addition to complementary feeding. Eighty-three percent are breast-fed with complementary foods between 6-9 months while at 20-23 months twenty-five percent infants are still being breast-fed. Moreover, those that are breast-fed, are not properly weaned. Although the percentage of infants breast-fed at 6+ months are encouraging, the percent of exclusively breast-fed infants are not. (28)

Exclusive breast-feeding provides a mechanism to target the diarrhea and malnutrition. The health benefits of exclusive breast-feeding include: ideal nutrition, early immunization, and oral rehydration for infants thereby significantly enhancing their chances of survival. Breast-fed infants are 25 times less likely to die of diarrheal disease and four times less likely to die of acute respiratory infections. Breast-feeding also benefits the mother through decreasing risk of cancer and osteoporosis while increasing the bond between mother and child. Breast-feeding is one of the most cost-effective interventions available to improve infant and child health. To prevent diarrhea, breast-feeding promotion is the least costly method. Rotavirus immunization is seven times more expensive while promotion of better hygiene behaviors is 15 times more costly, and cholera immunization is 200 times more expensive.(29) Since breast-feeding promotion has such a low cost ($.50 to $2.50 per birth in most countries),(30) it not only saves lives but it also saves money at the household, national, and international levels. Breast milk is the only food resource that is free. Breast-feeding eliminates the need to buy artificial milk and bottles thereby saving time in preparing bottles and reducing the environmental impact from producing, distributing, and disposing of artificial milk and containers.(31) In addition, breast-feeding reduces health care costs because it is a natural source of immunization. Breast-feeding can also assist in family planning because it contributes to child spacing. For these important health and economic reasons, the World Health Organization (WHO) recommends that children receive breast-milk until 4-6 months exclusively.(32)

The Ministry of Health in Haiti has published a Strategic Plan for Reproductive Health Services 1996-2000, which identified access to family planning as a primary goal. In this plan, it established a goal of reducing total fertility rates (TFR) from 4.8 to 3.6 within five years. It also estimated that 40 percent of Haitians have no access to health services. A number of institutions are collaborating to develop the capacity of existing public sector service providers to offer basic reproductive health services. Private sector health institutions have proven their ability to proved high quality services to under-served populations. Their performance in rural areas is particularly noteworthy. While this is a great effort by the government, it is known that many adults have many children because they feel that they need to have many to ensure the survival of some. If, in addition to the services both the private and public sectors intend to provide, there could be an educational component of how to take care of your children to ensure their survival, perhaps we would see a natural reduction in the TFR’s. Since breast-feeding has been shown to naturally reduce the total fertility rate, a crucial component of this education would be on the importance of exclusive breast-feeding and the appropriate times and foods for weaning.(33)

General education about breast-feeding is lacking, however there are many existing strengths within Haiti's health structure that we can enhance. Haiti already has two "baby-friendly" hospitals - hospitals that encourage mothers to breast-feed their newborns.(34) However, we would like to advocate for more baby-friendly hospitals. Within public hospitals, doctors and nurses suggest breast-feeding to new mothers; however there are still many who encourage formulas instead. Moreover, when women are encouraged to breast-feed they are not taught the importance of exclusive breast-feeding and proper weaning practices. For example, 48% of women do not give colostrum! So while 98% of women initiate breast-feeding, only 3% breast-feed exclusively. Finally, it is our goal to assist the government in creating a national exclusive breast-feeding policy through lobbying legislators and networking with non-governmental organizations.

Haiti has a strong and widespread traditional belief and practice system. Some of these traditional beliefs hinder breast-feeding practices. For example, in the first month of life, in addition to breast-milk, 79% of babies receive liquids (other than water) and solids. Furthermore, many babies are given liquids to "clear their stomachs" before they receive breast-milk. Another common misconception is that women who feel that they are malnourished do not breast-feed their children. ICPBF will attempt to provide the education for proper breast-feeding practices.(35)

In addition to cultural barriers, Haitian women are discouraged from breast-feeding because of logistical constraints. For example, many women use artificial milk in conjunction with breast milk because they work outside the home.(36) We will advocate for women-friendly workplaces where women are allowed and encouraged to breast-feed at work.

In a country where the prevalence of HIV is high, many would be hesitant to breast-feed, as this increases the chance of transmitting HIV to the baby by 14%. However this risk needs to be weighed against the dangers posed by artificial feeding. Given the inadequate sanitation and poor availability of clean drinking water, the dangers posed here seem more daunting. In these situations, death from diarrhea is fourteen times higher in artificially fed children than in those who are breast-fed. If women abandoned breast-feeding without safe and reliable alternatives, the number of infant deaths from diarrhea and respiratory infections could greatly outnumber those from HIV.

Given the overall situation in Haiti concerning breast-feeding practices, ICPBF’s potential areas of intervention are numerous. Granted ICPBF cannot address all of these challenges at a national level, but as one of the principal organizations in Haiti devoted to encouraging breast-feeding practices, it has a mandate to respond to unmet need in this domain.

After a careful assessment of its current programs and possible avenues of future programmatic interventions, ICPBF has found it most feasible to work with the government to implement a breast-feeding policy, launch a national IEC campaign, and train breast-feeding coordinators to educate women.

Breast-feeding for Healthy Children will be solely funded by IH887 for the five year duration of the project. At the end of the five years, outside funding will not be necessary as Haiti’s Ministry of Health will assume responsibility of in-service training and printing of IEC materials.

The national policy will include: increasing the number of baby-friendly hospitals in Haiti, creating women-friendly places where breast-feeding is allowed and encouraged (at home, in the workplace, and in public); incorporating breast-feeding initiatives into existing health policies, incorporating exclusive breast-feeding practices into primary school curricula, and initiating laws that support breast-feeding.

Activities 1. Training of nurses and doctors.

Medical doctors and nurses are the first contact with the mothers who deliver in hospitals. They also interact with mothers when giving curative, pre-natal, postnatal care and during immunization for their babies. Most of the health education is given by nurses and doctors as part of their daily activities when giving care to the patients. Training of medical personnel aims at creating awareness to the medical personnel about the health benefits of exclusive breast- feeding and ways to promote it. The 233 doctors and 350 nurses working in the ministry of health will undergo the training. The project will train 18 nurses and 2 doctors selected from the government institutions to form a core training team. Nine Department public health nurse supervisors will be included in the training and will integrate supervision of breast -feeding into their activities.

In Haiti, the government uses primary health care strategy to reach the community with health service. This is done through training community health workers to carry out health education messages on common health problems in the community. This project will train two volunteers selected from the women groups in each community to promote exclusive breast-feeding activities (266 volunteers).

School children are identified as a community resource in passing health messages to their parents and siblings. Schools also influence molding of a child's behavior. To influence positive behavior towards exclusive breast-feeding of babies under 4 months, the project will train 2 teachers selected from all the one hundred primary schools in the country who will integrate the content of breast-feeding in health and hygiene subjects (200 teachers).

4. Training of traditional birth attendants

Traditional birth attendants are a respected group of people in Haiti and are able to reach most of the mothers during their antenatal period, delivery of the babies or after delivery. This project will train 133 traditional birth attendants currently practicing in the communities. The traditional birth attendants will educate mothers on benefits of exclusive breast-feeding and proper weaning habits and follow them up in their homes.

The project will hire a consultant to develop a training curriculum and field reference manual for the medical and other community health workers (see Annex 8b).

The project will send 9 Department public health supervisors for a management course offered at Boston University School of Public Health. These coordinators will be responsible for breast feeding activities in all the district hospitals.

To change the social norms on breast- feeding in Haiti through:

• country -wide information and education campaign
• encouragement of community participation in the breast feeding initiative

One of the obstacles to a successful breast feeding initiative is overcoming the cultural beliefs and practices associated with breast-feeding in the country. The activities of educational information will address the current beliefs and practices on breast-feeding. The target audience of the information and educational campaign is the population of the entire country. The campaign would include radio and TV advertisements for three years, distribution of materials and community participation. A local media consultant will be hired to develop a slogan, a logo and produce radio & TV commercials, brochures and posters about the benefits of exclusive breast-feeding (see Annex 8c).

1. Press conference

The President of Haiti will launch the breast-initiative project in a press conference. The press conference will take place after the training of the first group of health personnel has been completed.

2. Media campaign

There are about 320,000 radios (1992 estimate) and 32,000 TV’s (1992 estimate) in Haiti. Therefore, a campaign using these forms of media will be very effective.

1. 1. Radio spot
2. Identify a popular Haitian singer or singing group and have him/her write a "catchy" song about exclusive breast-feeding and its benefits. Artist will donate work.

 

 

2. TV spot

3. Identify a high government figure (President, cabinet member) and persuade him/her to appear in a TV spot with mothers and their babies encouraging exclusive breast-feeding. The audio part of the spot could also be played in radio stations.

1. Community participation

Interventions will be created to involve the community in the breast-feeding campaign. Community participation is an imperative part of our campaign as it will both bring the communities together to work toward one goal and impart a sense of ownership of the initiative.

As of April 1st, 1998, Haiti had only two Baby-Friendly Hospitals. In 1991, UNICEF and WHO initiated the Baby-Friendly Hospital Initiative (BFHI) which supports a women’s right to breast feed free of advertising and promotional activities for breast milk substitutes. In the hospitals, the mothers receive help and support in their breast feeding efforts. In order for a hospital to become a BFHI, it must apply for a Certificate of Intent included in the application package. Then interviews and a site visit are conducted. The review board for Haiti then decides on the award of BFHI.

2. Train all health care staff in skills necessary to implement this policy.

3. Inform all pregnant women about the benefits and management of breast-feeding.

4. Help mothers initiate breast-feeding within a half-hour of birth.

6. Give newborn infants no food and drink other than breast milk, unless medically

indicated.

8. Encourage breast-feeding on demand.

10. Foster the establishment of breast-feeding support groups and refer mothers to them on discharge from the hospital or birth center.

Technical Plan

The following information will be a focus at the meeting.

1. Creating hospital breast-feeding policy
2. Practicing "10 steps" to the baby-friendly hospital
3. Reducing supplies from commercial breast-milk substitute
4. Conducting education classes about breast-feeding for new mothers by nurses
5. Celebrating World Breast-feeding Week from 1 to 7 August each year

To establish a sustainable mechanism for monitoring and evaluating breast-feeding activities in the public health sector.

1. A Breast-feeding Director will be appointed from within the Preventative Health Division at the Ministry of Health (see Annex 4)

Activities 1. Ministry of Health representatives will identify the appropriate

person to assume the role of Breast-feeding Director.

2. Breast-feeding Director will assume his/her position within the initial six months of the project.

The Breast-feeding Director will be responsible for oversight of the project throughout the public health system and will work in close coordination with the Country Director of the ICPBF. The Breast-feeding Director will assimilate information and data collected at the regional level and will prepare annual reports on the progress of the project. The activities of the Breast-feeding Director will continue beyond the duration of this intervention (at which time he/she will report directly to the Minister of Public Health and Population), and will be sustainable for the long-term. This is a half-time position.

2. Nine "Breast-feeding Coordinators" will be integrated into the public health system at the regional level (see Annex 4)

A reporting form will be developed for use in health centers to quantify the number of mothers exclusively breast-feeding. When mothers bring their children to the health center to have them vaccinated, and in the field during vaccination campaigns, nurses ask them five questions related to their breast-feeding practices and record their responses on this short form. The forms will be collected by the Breast-feeding Coordinators during their bi-monthly visits. Proportion of women exclusively breast-feeding will thus be incorporated into the Breast-feeding Coordinators’ quarterly reports as part of the Process Evaluation.

The Country Director, Program Officers, and Finance Officers will meet every four months at a fixed date to review expenditure reports, budgets and surplus money for activities. At the end of every year, a comprehensive finance report will be made by the

Finance Officer and reviewed by the Country Director.

Process Evaluation (Monitoring) (see Annex 5)

The Breast-feeding Coordinators are largely responsible for conducting the process evaluation. The doctors and nurses at the health centers will document the breast-feeding activities conducted in their districts. These activities will range from orientations given to individual mothers, to numbers of community talks given by traditional birth attendants (reported by TBAs to the health center), to number of women’s group meetings held. Number of attendees and a description of the specific intervention will be collected for each activity. The Breast-feeding Coordinators will visit each health center in their respective departments at least once every two months to gather epidemiologic data on number of cases of diarrhea and malnourished children less than one year old, collect information on exclusive breast-feeding promotion activities, and witness a training or community talk. A comprehensive list of indicators that the Breast-feeding Coordinators will compile appears in the table below. The Breast-feeding Coordinators will submit quarterly monitoring reports on the aforementioned information to the Management Program Officer and to the Breast-feeding Director. The Breast-feeding Director will submit annual reports as to the status of the program to the Country Director of the ICPBF and the Minister of Public Health and Population.

Three Knowledge, Attitude and Practice (KAP) surveys will be conducted during the period of the project, one at project initiation, one after year two, and one at the end of year four. The purpose of these surveys is to get a baseline understanding of the basic knowledge, attitudes and practices regarding breast-feeding, exclusive breast-feeding, and weaning, to then compare with knowledge, attitudes and practices after the intervention has been implemented. The year two KAP will serve an important purpose, that is, allowing for assessment of how the project is impacting the community and if the project is making progress toward achieving its goals. If this is found not to be the case, adjustments can then be made to the intervention in a timely fashion. The ICPBF will contract with an outside survey organization to do a KAP household sample survey. This survey will elucidate the proportion of women exclusively breast-feeding, and can be compared with the data collected through the process evaluation on the MIS form.

Outcome Evaluation (see Annex 6)

Information is collected by the Ministry of Health and will be analyzed for statistically significant changes between the year before the intervention was implemented and the year subsequent to the intervention. Two intermediate outcome variables will be analyzed, namely, number of cases of diarrhea and number of malnourished children less than one-year-old, as the project anticipates seeing a decrease in these variables by 30 percent. Ministry of Health infant mortality statistics will be analyzed, as the long-term goal of the project is to reduce infant mortality by 20 percent. The Ministry of Health Data will be compared with data collected by the Macrointernational Demographic and Health Surveys for accuracy. We will compare the data collected by the DHS for exclusive breast-feeding in children 0-3 months, cases of diarrhea in children less than one-year-old, number of malnourished children less than one-year-old, and infant mortality rate.

See Annex 7 for activity and indicator summary.

Sustainability is the most important facet of the project. We have designed the project to last five years but the effects will remain for years to come. For example, the policy conference will take place with the first year of the project. The Policy Program Officer will monitor and analyze the policies created and modified for the next four years. The Policy Program Officer will also lobby legislators and health department personnel. By the end of the project, a national exclusive breast-feeding policy will be in place. The establishment of a national exclusive breastfeeding policy will ensure that exclusive breast-feeding is a common practice in Haiti.

In order to incorporate the exclusive breast-feeding policy, Baby Friendly Hospitals will be established. The Baby Friendly Hospital Initiative will be sustained by the following activities: annual refresher courses for new health professionals, monthly health education sessions for new mothers, finding alternative funding for breast-feeding promotion, and promoting cooperation and collaboration among hospital staff, mothers, and community. These activities will be sustained through fundraising in the private sector and collaboration with other NGOs supporting exclusive breast-feeding.

To ensure sustainability, the project aims to integrate breast-feeding activities into the current Ministry of Health system. This will be achieved in a number of ways. The Department Public Health Nurses (Breast-feeding Coordinators) will be trained in management to improve the current skills and to incorporate supervision of breast-feeding activities into the current system. These Breast-feeding Coordinators, as well as the Breast-feeding Director they report to, are not positions that are created by this program, rather, they are transformations of currently existing positions within the public health system. Thus, their salaries fall within the existing Ministry of Health Budget.

A core training team composed of 18 community nurses and 2 doctors will carry out training of other medical personnel and community health workers. Training of volunteers and traditional midwives selected by the community will improve communication, collaboration and networking between the health system and the community thereby producing long-term sustainability and improvement of exclusive breast-feeding. Also, integration of breast-feeding into primary school curricula will create positive attitudes and knowledge base on benefits of exclusive breast-feeding among adolescents and youth before they begin having families of their own. The IEC materials will be produced, printed and distributed with money from the project for the first 3 years and then money will be allocated from the government through the MOH for the subsequent years for continued printing and distributing.

1 Country Director $40,000

3 Program Officers (30,000/year x 3) $90,000

1 Financial Officer $30,000

2 Secretaries (6,000/ year x 2) $12,000

2 Drivers (2400/ year x 2) $4,800

1 Messenger $2,400

1 Maintenance Worker $1,200

50% of Salary $90,200

Stipend for breastfeeding expert to plan policymaker conference and write report $2000

1 Media Consultant (8 months) $20,000

Illustrator for posters $300

Field Visits $500

Staff Travel to the US (2 trips/year/staff x 700) $7,000

Office Furniture $5,000

Office Equipment $2,500

3 Computers (800 each x 3) $2,400

2 Vehicles (20,00 each x 2) $40,000

Audiovisual Equipment $700

1 Moped $500

Office Supplies $200

Stationary $300

Subtotal $51,400

Office Rental (500/month) $6,000

Advertising:

Radio spot (artist donating his/her time) $800

TV spot $1,200

TV & Radio Commercials (air time for 1 year) $1,000

Equipment Maintenance $500

KAP Survey $5,000

Teachers pamphlet on breast-feeding $2,000

IEC materials $2,000

Drama Troupe (materials, transportation) $2,000

Other:

Two thousand plastic containers $1,500

One thousand Baby sling cloth carriers $5,000

Hiring of consultant (200 per day for 45 person days) $9,000

Printing of training curriculum (3 x 40 copies) $120

Printing of field workers manual (3 x 1476) $4,428

Consultant fees (200 x 7 days) $1,400

Meals and accommodation (70 x 30 x 5 days)

( participants &Consultant) $10,500

Per diem (10 x 29 x 5 days) $1,450

Stationary (5 x 29) $145

Trainers fees (50 X 2 trainers x 3 days x 7sessions) $1,050

Meals and hall charges (2 x 30 x 3 days x 7sessions) $1,260

Transport (3 x 30 x 3 days x 7sessions) $1,890

Per diem (10 x 30 x 3 days x 7sesssions) $6,300

Stationary (5 x 30 x 7sessions) $1,050

Trainers fees (50 x 2 x 1 x 4 sessions) $400

Meals and hall charges (2 x 117 x 1day x 4 sessions) $936

Transport (3 x 117 x 1day x 4 sessions) $1,404

Stationary (5x 117 x 1 day x 4sessions) $2,340

Return air fare (600 x 5 persons) $3,000

Tuition (8,000 x 5 persons) $40,000

Meals (500 x 5 x 3 months) $7,500 Housing (1000 x 5 x 3 months) $15,000

Miscellaneous (1000 x 5) $5,000

Departure (200 x 5) $1,000

Total $71,500 Subtotal $115,173

Strategic Planning Conference for Policymakers:

Printed materials $500

Meals (2 x 3 meals/day x 2days x 30 participants) $360

Subtotal $860

Contingency 10% $56

Per Diem (10 x 50 participants) $500

Stationary (3 x 50 participants) $150

Refreshment (3 x 50 participants) $150

Hall charges $100

Miscellaneous $100

Postage $300

Telephone/Fax (1200/month) $2,400

Utilities (300/month) $3,600

Bank Charges (8/month) $96

Employment Advertising $1,000

1. Salaries $902,000

2. Benefits $451,000

3. Travel and Associated Expenses $37,500

4. Supplies and Equipment $53,600

5. Purchased Services $38,500

6. IEC $20,500

7. Training $215,923

8. Policy Conference $1,236

9. General Administration $32,980

10. Fees $22,300

11. Baby Friendly Hospital Advocacy Meetings $1,000

12. Construction of Rooming-In Rooms (17 x $20,000 +$1700 supplies) $35,700

13. Assessment for BFH Status ($10x 5x17) $850

14. Award Ceremony for BFH Status ($100x17) $1700

Health Sector Reform Plan (HSR): The New Health Policy of 1996 ensures access to health care for all while recognizing that health is a fundamental right. The Health Sector Reform (HSR) "is being designed as part of an effort to decentralize the government so as to ensure equal access to a minimum package of quality services and greater profitability of health actions."(39) The incorporation of the exclusive breast-feeding policy into the HSR will ensure its survival and increase its effectiveness.

Code of Marketing of Breast milk Substitutes: The promotion of breast milk substitutes by the infant food industry undermines attempts to promote breast-feeding. The 1982 World Health Assembly adopted the International Code of Marketing of Breastmilk Substitutes which was drafted by WHO, UNICEF, NGOs, and representatives of the infant food industry. "The Code establishes minimum standard to regulate marketing practices by setting out the responsibilities of companies, health workers, governments, and others and provides standards for the labelling of breast milk substitutes. Among its provisions are that health facilities must never be involved in the promotion of breast milk substitutes and that free samples should not be provided to pregnant women or new mothers."(40)

1. Number of policymakers who attended conference.
2. Number of baby-friendly hospitals.
3. National breast-feeding initiative incorporated into existing 1996-2000 Health Plan of the Health Sector Reform Plan (HSR).
4. Laws passed to support Code of Marketing of Breast-milk Substitutes
5. Exclusive breast-feeding curricula incorporated into primary school health/science classes.
6. Laws passed to create women-friendly workplaces.
7. Number of women-friendly workplaces.
8. One breast-feeding expert hired and working.
9. One training consultant hired and working
10. Curriculum developed.
11. Field workers manual produced.
12. 266 doctors trained.
13. 350 community nurses trained.
14. 266 volunteer workers trained.
15. Proportion of villages represented in the training
16. 133 tradition birth attendants trained
17. Proportion of villages represented by the traditional birth attendants
18. Number of meetings volunteer workers have convened to discuss breast-feeding.
19. 9 Public health nurses trained.
20. Number of women groups formed and working
21. Number of performances of drama troupe
22. IEC materials created and disseminated
23. Percentage of the population that knows about exclusive breast-feeding.
24. Percentage of breast-feeding practices among newborn babies in the hospital
25. Percentage of trained personnel in the hospital
26. Number of education sessions for new mothers in the hospital
27. Number of Breast-feeding Coordinators trained in management.
28. Number of Breast-feeding Coordinators trained with other MOH staff about exclusive Breast-feeding practices.
29. Number of Breast-feeding Coordinators who keep logs of visits to district facilities.
30. Number of Breast-feeding Coordinators who submit quarterly reports to Breast-feeding director and to Program Officer of the project.

1. National policy created
2. Knowledge and practice of exclusive breast-feeding and appropriate weaning practices.
3. Proportion of mothers exclusively breast-feeding while in maternity wards.
4. Proportion of traditional birth attendants encouraging exclusive breast feeding after training
5. Proportion of doctors and community nurses counseling mothers on breast-feeding after their training.
6. Proportion of mothers breast feeding exclusively within 4 months of a babies life
7. Proportion of mothers giving colostrum to their babies.
8. Proportion of villages represented by the traditional birth attendants
9. Proportion of BFHs
10. Proportion of rooming-in rooms built

Consultant to plan national policymaker's conference on exclusive breast-feeding and to write a final report.

Minimum qualification will be Haitian citizen and hold a M.D. in pediatrics from a recognized university. She/he will have specialized knowledge in exclusive breast-feeding practices and experience in writing technical reports and planning conferences. She/he will have medical experience in Haiti and knowledge of Haitian customs/beliefs. Publication of research on breast-feeding practices in Haiti is a requirement. Familiarity with legislative system and policy is an added advantage.

The breast-feeding expert will work under the Policy Program Officer and be assisted by the two interns. The expert will plan a conference for Haitian policymakers to encourage the creation of a national exclusive breast-feeding policy. The expert will have six months to plan the conference and two months to write the final report. She/he is expected to be familiar with the project objectives.

The consultant will be employed for 8 months and will receive a stipend of $2000.

Consultant will develop a slogan, a logo, and produce radio & TV commercials, brochures and posters about the benefits of exclusive breast-feeding.

Minimum qualification will be a Haitian citizen fluent in English and holding a degree in Communications or related field from a recognized University. She/He will have at least 3 years experience in developing and conducting media campaigns, especially TV and radio commercials.

The consultant will be answerable to the project Director of ICPBF and will work closely with the project manager of ICPBF for capacity building and IEC.

She/He will be responsible for all aspects of the media campaign (press conference, commercials, slogan, brochures, etc.) and hire an illustrator/artist to create posters for the campaign.

The position will extend over eight months with a salary of $20,000.

Consultant to develop breast feeding training curriculum and field reference manual for nurses, doctors, community workers and conducting training of trainers.

Minimum qualification will be Haitian citizen and holders of BA in education or Social Science from a recognized University. She /He will have experience in curriculum development and at least five years teaching experience in a community health project in Haiti. Working experience in the ministry of health will be an added advantage.

The consultant will be answerable to the project Director in the ministry of Health and will work closely with the ministry staff, local community and the donor in developing the training curriculum and the field reference manual.

She/ He will conduct a five day training for 20 Trainers and 4 coordinators who will form a core training team for other health professionals, community members and coordinate breast feeding activities in the districts respectively.

She/ He is expected to be familiar with the project objectives.

The consultant will be employed for 52 days, with a salary of $10, 500.

ICPBF's Country Director for Haiti was the Executive Director for March of Dimes. She has extensive experience in project planning and developing, with special expertise in maternal and child health. She speaks fluent English, French, and Urdu. Her academic qualifications are M.D, MPH, MBA.

The Country Director will oversee all the Program Officers and the Finance Director. She will also collaborate with Haiti's government whenever necessary.

The position will last for five years. The salary will be $40,000/year.

The candidate will have medical degree with postgraduate training/degree in public health or MCH. He/She should have skills to develop and evaluate country programme on breast-feeding and extensive experience ( at least 5 years) in public health, especially in the planning and implementation of community-orientated health programmes at the national level and in developing countries. Excellent knowledge of written and spoken English is preferred. Knowledge of Haiti is an asset.

Job Description

The Capacity Building officer will provide advice to the Director on the planning and development of programs to promote breast-feeding practices and participate in the planning, implementation, monitoring and evaluation of all activities having components related to BFHI. He/She will assist in the establishment and coordination of BFHI programmes related to ICPBF and assist in the training of doctors and nurses.

The position will last for five years. The salary will be $30,000/year.

The Policy Program Officer is an expert in international health policy. She has a DrPH in Health Policy from UCLA and has worked in the international health field for 10 years. She has been with ICPBF for 5 years and previous to her present post, she was a Health Policy Analyst for UNICEF. She is fluent in French, English, Italian, and Farsi.

The Policy Program Officer will lobby Parliament and the Ministry of Health to adopt a national exclusive breast-feeding policy. She will also oversee Breast-feeding expert and assist in the planning of the Policy conference.

The position will last for five years. The salary will be $30,000/year.

The ICPBF Management Program Officer (MPO) has been working in the field of International Health for 7 years, and has been with ICPBF for 3 of those years. She has dual Masters Degrees in Public Health and Business Administration, both from Boston University. She is fluent in English, French, and Spanish.

The MPO will be responsible for managing the Institutional Organization and Training components of the project. She will work closely with the Breast-feeding Director and Breast-feeding Coordinators, as well as the Training Consultant.

The position will last for five years. The salary will be $30,000/year.

The ICPBF finance officer has been working on projects as a consultant in developing countries for 10 years and has been with ICPBF for 5 of those years. He has a Masters of Business Administration in Health Care from the Heller School at Brandeis University. He is fluent in English, French, and Spanish.

The finance officer will be responsible for all finance aspects of the ICPBF project in Haiti. Those will include budgets, working with donors, paying salaries and all expenses.

The position will last for the five years. The salary will be $30,000/year.

40. The State of the World's Children, 1998. Focus on Nutrition. UNICEF (http://www.unicef.org)