Introduction

Sustainable development planning and implementation is a multi-faceted task owed to the participation of many stakeholders across sectors, backgrounds, and localities. It is often observed that although top-down sectoral planning is the common practice, fortification from a bottom-up method is usually not well promoted [1-2]. In many instances, the upstream and downstream effects of development strategies — especially at the brink of emergency — are not thoroughly investigated nor outlined before intervention. Hence, communities with constituents living in poverty have been receiving foreign aid from wealthy communities for years. In this paper, we will focus on Haïti, which has a population of about 9.8 million and is the poorest country in the Western Hemisphere. The objective of this work is to introduce an institutional partnership model that includes a multi-stakeholder development-planning context, based on principles of sustainable development. Institutional development became an established approach for premising and evaluating stable performance. The advantage of institutional development is the holistic systems viewpoint and the identification of upstream and downstream costs and benefits that contrast service delivery. The approach is demonstrated using a selected case study, the partnership between the Université d’État d’Haïti (UEH) and the University of California (UC) as well as a concurrent subproject within the Institutional Partnership. The case study specifically outlines principles of institutional development framework from reconstruction planning and implementation stages and the subproject’s evaluation methodologies are introduced for initiatives in capacity building initiatives and public higher education. It was found that the framework led to a growing effort for innovation in sustainable development and promotes cross-sectoral stakeholder participation and integration.

Background

There are approximately 10,000 registered non-government organizations (NGOs) in Haïti. Many of these NGOs have been extensively effective at providing critically needed services to fill gaps normally occupied by the public sector. According to United States Government data, 76% of the Haïtian people still live below the poverty line and 54% live in extreme poverty; since 1970, the people have seen real per capita GDP fall by 30%. The conditions observed in Haïti can be found in localities around the globe: communities living in severe poverty yet supplied with aid by multiple international aid organizations. Not only did the earthquake of January 2010 draw the global attention to Haïti but also it exacerbated all aspects of its inherent development challenges. The needs of Haïti’s citizens dramatically increased and the support they were receiving radically amplified. And yet, with more help arriving in every form, seventeen months have passed, and the people of Haïti are not faring better.

Consequently, it is human nature that mandates helping fellow men and women in need. The desire to assist a person enduring hunger, sickness or difficulty is engrained within us.This trait is well documented, as psychologists classify people lacking this empathic drive to be pathologic, having sociopathic personality disorder or autism. And yet, in day-to-day life, most of us do not constantly engage in altruistic activities. As a society, we have created a social system to do this for us. Most of us go about our day, confident in the many social institutions that make the fabric of a developed Western society. We have created institutions that care for the ill, poor and disabled. This absolves many of us of from the constant compelling need to help those around us. However, the earthquake that struck Haïti vibrated that tribal primordial chord within us to help fellow communities in need. We instinctively knew that unlike the homeless people outside our doors, and the hungry children of poor inner city families, the Haïtian people have few institutions that can meet the acute burden. We, as a world community, were driven to help.

The problem with this human drive is that like many other human impulses, altruistic action does not always produce the desired outcome. Helping a fellow man or woman makes sense on a small scale, and with temporal limitations. But, when this action is vastly multiplied and extended to last years, its implications are felt on many unexpected levels, and its consequences are often deleterious. In delivering altruistic help, the individual often considers only the short-term physical impact this help has on the intended recipient, whereas the altruistic act’s social, economic, political, and long-term physical implications has gone overlooked [3].

The health sector is one such case. Since the earthquake, tens of thousands of healthcare providers volunteered in Haïti on relief missions. For the two weeks following the earthquake, many lives were saved by the acute care provided by volunteers. But after that, most volunteers were treating chronic non-earthquake-related conditions. Generally, patients were arriving at the free clinics with malaria, tuberculosis, headaches, chest pains, and all the same medical problems that existed before the earthquake (mental health, rehabilitation, post-traumatic disorders, and the cholera epidemic are four notable exceptions). Post-disaster relief is distinctly different from long-term development [4]. Natural disasters, man-made disasters, and any event that severely incapacitates existing institutions require and ethically mandates external help based on philanthropy and volunteerism. But, such help must be limited to addressing only acute needs created by the disaster, and must set clear goals based on the anticipation of rapid withdrawal. To avoid unintended consequences, help provided in this manner must be short in duration and limited in scope; assistance lasting more than two weeks becomes development work, rather than disaster relief.

When development work is approached like disaster relief, unintended consequences occur. Prior to the earthquake, most health facilities use a fee-for-service system. The earthquake brought with it exponential growth in the number of facilities providing free medical care; in fact, the government mandated free healthcare provided by all institutions for nearly six months following the earthquake. The many months of easily available free medical care prompted many Haïtian healthcare providers to leave the Haïtian medical system. Providers from all groups expressed dissatisfaction with the scope and quality of care provided at public health facilities, as well as disappointment with the reduction in patient volume at private practices [5]. Many providers looked for work in neighboring countries or with foreign NGOs, which pay higher salaries than Haïtian institutions, left Haïti, or simply remained out of business and unemployed. Eventually, the effects of ubiquitous free healthcare were appreciated, and the government mandated that all institutions must charge some fee for the services.

The sort of help provided to Haïti erodes the healthcare system and creates dependency. Such a system provides healthcare, but does not hold itself accountable to the people served, since it is sustained only by donations and grants from foreign institutions. Furthermore, once such a system is in place, cultivating an effective, financially viable system is nearly impossible [6]. Volunteers feel that they are helping, but often fail to consider that every society has limited resources—and to some degree—all resources will not be available to every member of a society. Every society, including the United States, has poor people that could use help. In the United States, there are people who cannot afford life-saving medications, there are people who cannot afford health insurance, there are people with physical and mental disabilities who do not get help, and many people die of preventable diseases. But, in the United States, we realize that having volunteers provide needed services may not be the best for society.

Hence, we humbly pose the question: why do those who have never volunteered in their own communities choose to volunteer to help the people of Haïti after the earthquake? If it is about helping individuals, then it should not matter if you help a poor single mother ill with asthma in Haïti or in Los Angeles. Why is there an impulse to purchase a plane ticket and fly thousands of miles but fail to drive twenty minutes to help people here at home?

We suspect the answer is that we see the plight: not only of an individual but also of an entire population. We try to answer the plight of a population, of a community, by helping individuals. Something inside us tells us that this approach would not work well at home. We recognize that in order to truly assist a community, one must strive to build institutions, not recruit volunteers. A poor community needs better schools, a better police force, financial institutions, healthcare institutions, etc. Helping one person for one day is beneficial, but in the grand scheme, such action will probably not make a difference for the community. And, helping one person too much for too long creates innate dependency. Ultimately, communities need permanent and locally sustained legal, medical, financial, political, education and social institutions functioning with as little inefficiency and corruption as possible. Volunteerism focused on free goods and services undermines and destroys institutions, and thereby, the very fabric of society. Years of volunteers and aid of every form have kept the poorest communities in poverty and created dependency. These communities started out as only poor; now, they are poor, dependent, and with weak or non-existent locally-sustained institutions.

The key to providing effective help is to ensure that institutions are created and fortified from the bottom up, not from the top down, and that these institutions are dependent on their constituents, rather than external entities, for their survival [7]. Institutions need to grow organically, composed of local stakeholders striving to meet the needs of their communities, according to the priorities set forth by their communities. While all individuals strive for health and prosperity, individuals function within communities. Communities decide how to invest limited resources, and one community has to cautiously impose its values and priorities on another. Doing so will lead to numerous unintended negative consequences. Help based on volunteerism has many shortcomings, not the least of which is misjudging the priorities of a community in need. Volunteers often assume that since people are using and appreciating the free good or service they provide, the good or service is vital, and necessary. There is high demand for free commodities in every community; one cannot assume that a need for a commodity exists simply because recipients accept something offered for free.

The true test of need is to ask the recipient of a good or service how much of their own resources they are willing to invest. Despite appearances, everyone has resources to invest. Resources include time, labor, opportunity cost, and so forth. Ultimately, we all divert our time and labor to produce something of value to our community.There are numerous examples of sophisticated Western-style hospitals donated to developing countries. These hospitals rarely become self-sustaining. The ventures often end up an exercise in frustration for the donor community, who fails to understand why the receiving community is not invested in the gift. Prior to construction, the donor agency will ask the receiving community, “Do you need a free hospital?” The answer is invariably “yes” as people rarely decline goods and services that are offered without expense. Then, once the hospital is built, the receiving community cannot invest resources over a long period to maintain it.

Communities have a right to set their own priorities in dealing with inequalities and limited resources; true development and innovation of community-based social change will follow from the establishment of effective, locally accountable and locally sustained, institutional partnerships.

Materials and Methods

After the earthquake in Haïti, a small group of students and faculty from across the University of California (UC) system spent many months studying the situation in Haïti. After hundreds of discussions, observations, and volunteership with Haïtian leaders, Haïtian citizens both rich and poor, experts in development, and thought leaders in numerous spheres, the group devised the following guidelines for promoting development in a community. These guidelines will be implemented in a bilateral partnership between the Université d’État d’Haïti and the UC system, which seeks to collaborate on providing innovative solutions for long-term development in Haïti. Although the two are academic institutions, any community or institutions believing in the fundamental notions of transferring skills or knowledge and igniting innovation can apply these guidelines. The binding partnership works to build links between individual agency, institutions, and community-based innovation to navigate transformative sustainability in Haïti. By addressing local needs, access to social, and technical information—institutional capacity building can reverse the trends that are challenging critical obstacles in sustainable development [8]. Thus, capable social and technical innovations with potential to change unsustainable trajectories need strong investment and connection to broad institutional resources and responses.

Additionally, this Institutional Partnership model utilizes a peer-to-peer mechanism that exerts innovation in global sustainable development through investment in public higher education and human capacity building initiatives. This Institutional Partnership operates to reproduce social structure as well as to increase productivity. The models aim to measure the valuation of how much human capital matters—by merger of the Institutional Partnership and the peer-to-peer mechanism—as a factor that facilitates innovation diffusion as well as a factor of production for social change.

We have premised that knowledge sharing between institutions is economically benefiting and will attempt to decipher the welfare tradeoff implications of this transfer of knowledge. We will mainly focus on whether our units of knowledge through public higher education or capacity building projects complement, substitute for, or are independent of the development of UEH constituents. We will be evaluating multiple indicators that infer reproducible outcomes such as generated externalities, knowledge spillovers that translate to economic activity and novelty of capacity building projects across sectors. Invention, research and development (R&D), technology adoption, and education-based solutions are viewed as the focal innovation-based forces for increasing the economic and social capacity of individuals involved in these projects. As the Haïtian society in relation to UEH becomes more modern, the educational system will reflect and reinforce the innovations to capacity building upon post-knowledge sharing application.

Hence, all agents share a common value function for knowledge. The utility of this notion is that it permits analysis of general payoff functions describing the rates of returns to investments that involve the transfer or acquisition of knowledge. Knowledge can be catalytic in the sense that it raises the value of other skills and thus accelerates social learning. Accordingly, these projects are apt to bring social change in resource-limited environments such as Haïti. The Institutional Partnership and peer-to-peer mechanism aims to convey that human capital facilitates diffusion of innovation precisely because it complements new techniques of production, such as expansion of R&D practices and increases in technology use and distribution. Complementary basic skills like numeracy and proficiency catalyze value adoption, and adoption may be path-dependent when payoffs are certain and self-governing across affiliated participants. Initial diffusion focused at the individual level, infers that a more “modern” individual will become one who hopes to adopt innovations more quickly, serving as an example to others in the Haïtian community. Additionally, initial diffusion focused at the institutional level, infers that a more open environment for innovation will come by a change in incentive structures, R&D, and evaluation when considering human and institutional capacity building within UEH.

We define “innovation” as “a technology that which improves educational outcomes, improves working relationships or processes within the society…or [that which] reduces the cost of services without significantly reducing the quantity or quality of desired outcomes or processes” [9]. We premise that knowledge transfer systems and innovation can be made more effective through rational planning and scientific development of new methods, while concentrating dissemination at the local level. We aim to reduce the barriers to diffusion of institutional and individual innovation. At times, educational ‘reform,’ ‘exchange’ and ‘innovation’ are used interchangeably yet we acknowledge the coherent differences between ‘reform’ and ‘innovation.’ Whereas ‘reform’ connotes a significant change in the direction of the educational institution, ‘innovation’ connotes a specific change in knowledge-based, programmatic practice—the latter is more relational due to its tendency to consist of more tactical steps. We maintain that both ought to be viewed similarly due to the complex socioeconomic and political forces that are generated during project implementation and with regard to the conditions in Haïti.

Results

This Institutional Partnership is seen as having socializing, integrative and adaptive functions that aid in the production of human capacity and in the creation of altered social climate necessary to operate in the socioeconomic development system in Haïti. For example, in technology adoption literature, it is stated that better educated persons are always consistently labeled ‘early adopters’ [10]; additionally, that countries with tertiary education systems appear to benefit more from foreign research and development. Hence, in practice, aggregated daily behavior of post-knowledge transfer or acquisition derived from this Institutional Partnership will not only accept new methods more often but also learn to communicate easier and become more productive. Development practice and innovation objective will vary across individual projects. The goal of each project is the transfer of knowledge-based skill to the recipient community. The skill should allow members of the recipient community to produce a good or provide a service previously unavailable. Each project has the following characteristics:

  • Peer-to-peer mechanism: A single person from each community must be designated to lead a project as a pair of collaborators. This guideline ensures that the recipient community recognizes the need or problem as a priority. If no individual in the recipient community is willing to invest time and energy in addressing a need, then the need must be of low priority and addressing it should be deferred.
  • The two project leaders are encouraged to work as partners. Each project must identify a specific set of problems or needs, which must be clearly articulated and agreed upon by both project leaders.
  • The project leader from the recipient community must lead the implementation of the proposed solution. The assisting community may play a supporting role, and contribute in every way, but leadership in implementation must come from the recipient community. A solution to a problem may seem simple and straightforward to an outsider, but this is rarely the case.There are often delicate economic, political, and social implications to addressing the need of a community. These can only be fully appreciated by members of this community.For this reason, the members of the community that they affect must deliver solutions.
  • All needs must be addressed with sustainable solutions.A proposed project must detail how a solution will address the need perpetually or permanently.
  • The community providing assistance may do so in the form of expertise, logistical support, and start-up assistance. Material and financial gifts that are not investments should be avoided whenever possible. Lending is always preferable to giving. At times, material or financial gifts are necessary to start a new institution.
  • The benefit provided by the project to both project leaders and both communities must be clearly identified. The community or individuals providing assistance must recognize that in some way, they benefit from the project. Identifying the benefit to all parties involved may expose motives, assumptions, and agendas that are not obvious. Projects should be viewed as a bi-directional symbiotic collaboration rather than on uni-directional “aid”.

The estimation of a knowledge-based or social rate of return begins with a cross-sectionalized distribution of innovation differentials by project. The savings on capital costs may measure the rate of social return for instructional purposes at UEH as well as opportunity costs and benefits to the Haïtian society through a product or service. Additionally there will be evaluation of non-pecuniary benefits accruing to the individuals participating in the partnership; enhanced ability, increased motivation, and higher technology adoption rates are all positively correlated with knowledge or innovation attainment. ‘Ability’ will be measured after formal training or knowledge transfer has been conducted. Thus, as individuals acquire knowledge through this Institutional Partnership, their productive contribution in capacity building initiatives will be enhanced. This can also be conveyed through increased or more accessible educational and employment opportunities. Thus, investment in knowledge as human capital can be construed as a significant determinant of growth and a factor of success. Rate of social return can also be measured by the participant’s inclination to make decisions that increases community efficiency. ‘Efficiency’ in this instance refers to an application that increases social value—knowledge-based innovations can be judged by their contribution to increased social efficiency. We will assess the cost of productive contribution of these projects through cost-benefit analysis for evaluating the worth of each ‘innovative’ project by change from before and after project implementation and cost of maintenance. ‘Adoption’ will be primarily based on increased collaboration on initiatives with social groups, efforts to bring changes in instructional methods or organizational structure within UEH and UC systems. In general, the general indication of accepted innovation and social change would be based on the interaction of social incentives with individual actions such as the service to enhance ties between researchers, innovators, developers, and practitioners within the Institutional Partnership.

An example project is training of a Haïtian clinician from UEH at the University of California, San Diego (UCSD). He is working with one collaborator in regards to his higher education training program design as well as one collaborator for the applied capacity building plans. His training in basic and medical Microbiology is currently on going and is under continuous evaluation and analysis for logical post-training frameworks to be applied upon return to his community. As it stands, the innovation in global sustainable development would be to invest in clinical diagnostic capacity building as well as aiding in new academic curriculum at UEH for medical and pharmacy students. This Haïtian collaborator will advance from clinical practitioner to holding higher-level positions in hospital health management and clinical education. The collaborators will benefit by prospective research of advanced methods transferred from advanced laboratory capacity to resource limited setting, to also new analysis objectives in knowledge transfer, R&D efficacy, and technology adoption rates.

In the first instance of considering human capacity building, we will examine the trainee’s individual adoption factor, focusing on possible structural problems that may not yield sufficient incentives to innovation or those that provide incentives that yield unfeasible innovation adoption determinants in the trainee’s local environment. We will assess with local stakeholders within UEH the general interest for increased regional and local health/R&D centers to adopt relevant technologies from his training as well as interest to modify advanced technology to better suit the community. In the second instance, we will evaluate any mutual adaptation perspectives that infer mutual benefitting between innovation disseminators and adopters — this is the foundation of institutional innovation. Consequently, we will note the participation of local stakeholders who are audience to the UEH trainees’ involvement in the appraisal of innovation in capacity building and public higher education. It will lead our assessment to detail the judgment of participating decision makers as potential innovation adopters and users. We predict that projects designed to promote greater rationality in institutionalized and individualized innovation will be favored; innovation projects that convey details from a needs assessment, a specific target group, and local stakeholder will more likely be supported financially. This Microbiology training project’s capacity building assessment will undergo all three mechanisms in addition to public reporting of the trainee’s examination scores, international learning experience, and competency test results. Through cost-benefit analysis and questioning of how the causal impacts will formulate the focus of such evaluations, we will then be able to decipher how they will become central to the capacity building activities.

Discussion

Following these guidelines will empower the members of a community to address their community’s needs with some outside support. Development in this form will lead to the creation and/or strengthening the capacity of local institutions. Furthermore, the community needs will be addressed in a culturally congruent manner, according to the priorities, ethics, and norms of the target community. The results of the principles transitioned to a more effective institutional partnership among private, public, and NGO providers from before the January 2010 earthquake and the humanitarian response that followed. Much like all institutional and social change processes, the innovation process is also complex and the data collection needed to predicate stronger relationships, organization and project outcomes remain poor. We conclude that the aforementioned factors are currently prima facie, ad hoc, and can be altered by different variances. The aforementioned training project will be one of many knowledge-based innovation projects that derive from this Institutional Partnership; it will act as a beginning baseline for empirical results and a foundation for optimism in the function of prospective research and development projects that will contribute to the development of new models to evaluate innovation. Given the plain indeterminacy of quantitative methods in the projects at this time, we note that evaluation processes may result in contradictions, biases, and conflict due to limitations of additional holistic analysis of the socioeconomic systems in Haïti. For these reasons, we will contend to limit outcomes based on individual’s innovation adoption, feeling of social contribution, and social change within the two partnering institutions at large. With respect to methods of analysis, there will be a continued drive to develop quantitative measurements related to R&D, increased local participation and analysis of changed incentive structures pre- and post-training application.

Limitations

Because of the novelty of this Institutional Partnership and peer-to-peer mechanism, it is still a working model. This factor may have biased the current discussion and results that require further investigation. The limitation enumerated here will be accounted for in a more thorough follow-up evaluation using the aforementioned process.