PEDIATRIC CARE: Yno Bertrand keeps a watchful eye over her infant daughter Carme-Suze Philippe inside a tent doubling as the pediatric ward of Haiti’s main and largest public hospital in Port-au-Prince, the Hospital of the State University of Haiti. PATRICK FARRELL MIAMI HERALD STAFF

In the aftermath of the Jan. 12, 2010, earthquake, Haiti’s largest public hospital went from a place of last resort to a life-saving refuge where the dead and dying lined the entrance, doctors operated with vodka and patients recovered inside tents.

Five years later, the tents are gone, and so are the buildings that collapsed under the weight of the 7.0 disaster. But a new 534-bed Hospital of the State University of Haiti (HUEH), the country’s key public healthcare facility, is still at least two years away from reconstruction, despite funding from international donors.

“The construction is advancing,” executive director Dr. Maurice Fils Mainville said, peering out of a window where heavy machinery could be seen leveling dirt on the horizon. “If everything goes as planned, there won’t be anything left to do or any foreign firms here by February or March 2017.”

One of the first projects approved by the now-defunct Interim Haiti Recovery Commission, the $82.3 million teaching hospital’s slow progress is indicative of the difficulties the Haitian government and donors have faced in trying to quickly restore what was lost in the horrifying tragedy that left more than 300,000 dead, an equal number injured and 1.5 million homeless.

Shortly after the disaster, the U.S. and French governments each pledged $25 million for the hospital’s reconstruction with then-French Foreign Minister Bernard Kouchner saying at the September 2010 signing that “without coordination, we’ll be very disappointed with the results, so it is an excellent idea to have this cooperation among the three of us for the University Hospital.”

Haitian officials say they have no idea how $50 million was arrived at but the amount was far from adequate to build the 269,937-square-foot hurricane-and-earthquake resistant steel structure.

“It hasn’t gone at the speed I would have liked,” Haiti’s Health Minister and acting Prime Minister Dr. Florence Duperval Guillaume said about HUEH, commonly referred to as the General Hospital. “But for the hospital to have been rebuilt faster, we would have had to close it.”

Haiti officials blame the slow pace on a number of factors, including flaws in the initial design and a multinational bureaucratic snarl from financial backers — France, the United States and Haiti.

It took 10 months before Guillaume could sign off on an international consulting firm, which determined more funds were needed, especially if health officials wanted to keep treating patients during the construction period.

“I don’t know if it’s only Haiti where it is like this,” Michaël De Landsheer, executive director of the Ministry of Finance’s Technical Execution Unit, which is managing the project, said about the lengthy process. “I don’t want to name names of other agencies or governments, but when I look at the people who are helping us here, I see that their bids also take time.”

Alhough France is the project lead, the hospital’s construction delay has been the subject of at least two critical U.S. government reports on Haiti reconstruction.

In a November 2011 report, the U.S. Government Accountability Office said that due to a U.S. government-required environmental assessment that took longer than planned, the United States’ signing of the agreement with Haiti and France was delayed by about five months.

Last spring, USAID’s Office of the Inspector General cited the construction in an examination of the agency’s $99 million Haiti health infrastructure program. In addition to the General Hospital, projects include several clinics and regional hospitals, and a rebuilt medical school as part of the National Campus for Health Sciences. The agency had hoped to have all done by December 2015, the audit said.

USAID Haiti Mission Director John Groarke said while the hospital is delayed, the process has been complicated and it was “symbolically important” for the U.S. to allow Haiti to take more of a leadership role in the rebuilding.

Jake Johnston, who has been tracking Haiti’s relief and reconstruction as a research associate with the Washington-based Center for Economic and Policy Research, said the hospital is a case study in how Haiti, USAID and the international community in general failed in their post-quake mission to “build back better” by improving coordination. A French Embassy official did not respond to an interview request.

“It’s emblematic of what went wrong. It fell back into business as usual, suffering from the same problems projects suffered from before the quake, which the quake response was supposed to address,” Johnston said. “The General Hospital is the heart of the public health system. This is what building back better was supposed to be, but it hasn’t had the success that smaller projects have had.”

Unfair comparison

Less than a mile from the downtown General Hospital, a newly rebuilt 125,000-square-foot St. Francis de Sales Hospital is preparing to receive its first patients when it reopens Jan. 15. The quake leveled most of the 100-year-old hospital’s buildings, killing 70 patients, visitors and staff. Operated by the Roman Catholic Archdiocese of Port-au-Prince, the 200-bed facility’s $22 million reconstruction was financed by the Catholic Health Association and its member organizations, Catholic Relief Services and the Sur Futuro Foundation.

Some 30 miles north, the 200,000-square-foot University Hospital of Mirebalais built by Boston-based Partners In Health stands in sharp contrast to the General Hospital. It opened within 18 months of construction, and stands as one of the largest solar-powered hospitals in the developing world, costing a fraction of the price of the General Hospital at $21 million.

“People sneered sometimes at the idea of, ‘You don’t need a helipad’ and ‘You don’t need a 200,000-square-foot hospital in the middle of central Haiti,’” PIH founder Dr. Paul Farmer told U.S. lawmakers in December. “Of course you do. They just lost all of their healthcare infrastructure.”

Haiti lost more than 50 hospitals and clinics in the quake, which struck the capital and surrounding cities.

Government officials say it’s unfair to compare the General Hospital’s construction with other privately built hospitals because they aren’t subjected to the same onerous requirements or laws requiring “no objections” before proceeding to the next step.

Also, while Mirebalais’ hospital rose out of an empty lot, the General Hospital has had to remain open as it rebuilds.

“Imagine, while someone is coming for consultation, a truck is coming in dumping dirt,” Guillaume said.

The hospital’s ongoing challenges are evident on any given day. Construction trucks operate as patients line the narrow walkways of the main building, while across the busy street, outpatient clinic visitors spill into a congested courtyard.

“In the morning, you have about 2,000 patients here waiting,” Mainville, the hospital director, said while giving a tour of the transitional facilities that had to be built to free up the land for construction.

Showing how an old military hospital and health ministry’s offices were retrofitted to now house radiology, dialysis treatment and the physician residents’ dormitories, he said, “something has been done. These didn’t exist before.”

The only tent that is left on the site houses the pediatric ward. Inside, sick infants lie in rusty cribs while worried mothers, such as Yno Bertrand, stand vigil. Bertrand was referred to the General Hospital from another facility with her feverish 6-month-old daughter.

Bertrand’s case is common at the hospital, which primarily caters to Haiti’s poor. Between October 2013 and September 2014, the hospital saw 215,155 patients, Mainville said. Only about 9 percent or 19,172, however, were hospitalized.

“The private facilities couldn’t absorb the volume of people we treat,” he said, noting that this is why “we couldn’t completely shut down the hospital and say ‘we’re waiting on reconstruction.’”

De Landsheer said building temporary facilities has taken time — and money, which has had to come out of donors’ contributions.

For instance, officials had to commission the construction of 90 beds for residents’ dormitories, which also had to be retrofitted with showers.

Though the agreement with France and the U.S. was signed in September 2010, Haitian officials wouldn’t realize that they would have a shortfall until February 2012 when they issued an appeal for firms to prequalify and present their construction designs.

“We told them $25 million is what we had to construct the hospital,” De Landsheer said. “Not a single person appeared. They looked at the money and said, ‘No, thank you.’”

Haiti was soon forced to add $30 million to its $3.2 million contribution. The additional funds were for staff training and equipment, but also to free up additional donor funds for the construction.

It would take 11 months and a second tender, however, before the government would finally sign a contract with a Spanish firm that has since hired some of the very Haitian companies that bid on the project but didn’t win, as subcontractors.

But before the winning firm could even send in the first bulldozer, its Spanish documents had to be translated into French. The process took five months.

“We lost a lot of time in the international bidding process,” Mainville said. “The process is really too long.”

Outpatient clinics

Even before the earthquake leveled a third of its buildings and crippled its services, the General Hospital was an overburdened, under-financed facility where politicians rewarded supporters with jobs, patients had to buy their own medicine, and doctors and nurses routinely went on strike.

U.S. officials say a key component of their commitment is helping Haiti maintain the hospital once it is built. The French are working with health officials to identify operation and maintenance needs while the U.S. is helping the hospital with management and financial accountability.

Guillaume welcomes the assistance, saying that she would like to see the plans completed.

“We need projects,” she said, “but we also need permanent financing.”

If the hospital’s patients’ statistics illustrates the importance of Haiti’s poor, it also points to another problem that Guillaume also has been trying to tackle: it functions as a vast outpatient clinic.

“Even if someone is suffering from a headache, this is where they head to,” she said. “We have to decongest HUEH so that it plays another role after it’s built. It’s like you’re building a house — at the same time you are constructing the foundation, you are also doing the roof.”