The current Government in Haiti seems unable, owing to political instability, natural disasters and funds mismanagement, to address the high rate of communicable diseases such as HIV-AIDS, cholera and tuberculosis, as well as to improve the primary healthcare sector and achieve Universal Health Coverage. A more accurate management of financial and human resources bound-up with a higher public investment in the health sector could help overcome the impasse
By Pietro Dionisio
EU Health Project Manager at Medea SRL, Florence, Italy
Degree in Political Science, International Relations Cesare Alfieri School, University of Florence, Italy
Haiti Healthcare Sector: Hard Recovery From Disastrous Years
Haiti faces huge challenges to its healthcare sector because of recurrent natural disasters such as earthquake and hurricanes (every year on average 1-2 hurricanes strike the island), making it hard for Haiti to recover or improve on its economy and keeping the Country in a constant crisis model and financial hardship.
Relevantly, the 2010 earthquake was the worst natural disaster striking Haiti in over 200 years; more than 220,000 people died, and 300,000 were injured. The earthquake had a catastrophic impact on an already fragile healthcare system, including the total destruction of, or damage to, 30 out of 49 hospitals in the disaster zone. Damages that are not yet completely recovered.
From an infectious diseases perspective, the situation is not running well now that, among other scourges, the main illnesses affecting Haitians are cholera, tuberculosis/MDR-TB and HIV-AIDS.
Even if official data are not completely reliable because of bias during data collection and monitoring, 3,111 suspected cases of cholera were reported in 2018, including 37 deaths, with an incidence rate equal to 25,5 cases per 100,000 population, which is the lowest, though still significant, recorded incidence since the beginning of the outbreak (2010).
What’s more, according to the “WHO Global TB Report 2017”, Haiti has the highest rate of TB in the Western hemisphere, with an estimated incidence of 188/100,000 in 2016. TB is even more present in some urban areas, with a rate beyond 1,000/100,000 in several slums of Port-au-Prince, the capital city. Additionally, in 2016, there were 15,567 reported cases of TB in Haiti, with an estimated 75% case detection rate. As concerns MDR-TB, WHO estimates that 2,9% of new cases and 13% of previously treated cases have MDR-TB/, with a total estimated number of 530 cases.
As for HIV-AIDS, according to the “Programme National de lutte contre la SIDA, Declaration d’engagement sur le VIH-SIDA, rapport de situation nationale, Haiti Mars 2016”, and the information bulletin released in December 2018, Haiti shows 7,600 new HIV infections and 4,700 AIDS-related deaths. There were almost 150,000 people living with HIV in 2016 with an access rate to antiretroviral therapy equal to 55% c.a.. Moreover, among pregnant women living with HIV, 71% were accessing treatment to prevent transmission to their children, at a time when an estimated <1,000 children were newly infected due to mother-to-child transmission.
Overall, new HIV infections have decreased by 25% (with a 24% decrease in AIDS-related deaths) since 2010, but have increased by 1% comparing to 1990.
If communicable disease is one of the major plagues in the Country, the backwardness and inefficiency of the healthcare system are not far behind. According to available data, despite the 2010 earthquake and the 2016 Matthew hurricane, the health outcomes have improved and health infrastructures have been re-built. However, the poorness of health equity and coverage measures, as well as the lack of water and sanitation services, that are below many other low-income countries, are slowing down progresses towards people health and infectious disease control. While Haitians can now expect to live longer, access to basic health services is still lacking.
The problems faced by the Haitian healthcare system also include the mismanagement of external financing together with poor access to, and poor quality of, primary care services.
In particular, the total expenditure for health has increased over the past 20 years mainly by external financing to NGOs, while the government has played an increasingly marginal role in financing the sector. The increase in external financing has changed the structural composition of health spending. In 1995, households were the main financiers of health system through out-of-pocket payments (46%), followed by the government (41%) and NGOs (13%). Since then, the government contribution has decreased substantially, down to 6.8% of national GDP in 2015. In the same year, out-of-pocket payments accounted for 36% of total health expenditure while NGOs and other private institutions serving households represented 44%. This context has resulted in a constant rise of external funding (featured by a low donors’ coordination) and in the lowering of domestic financing.
As mentioned, another issue undermining the Haitians’ quality of life is the poor efficiency and representation of public primary healthcare sector. According to an official report released by the Haiti’s health minister on the assessment of the quality of healthcare services, the private sector is dominant compared to the public one. In fact, out of 1,033 health institutions in the Country, just 350 are public against 493 private, whereas the remaining 190 show public-private co-participation. Moreover, only 32% of public health facilities in Haiti provide essential medicines, and only 31% possess basic medical equipment.
Under the circumstances highlighted so far, the Government should implement a strong national strategy in order to make the healthcare system more reliable and efficient.
Since financial and geographical access are key obstacles for citizens, the Haitian Government should invest more and more efficiently on primary care sector including by improving on transport system and telecare. Additionally, the Government should capitalize more on health professionals training and distribution across the Country. In fact, according to the aforementioned report, while almost 19,100 health professionals are at population service within the different public and private health institutions, unfortunately, they mainly consist of nurses, i.e. 8,202.
Medical professionals account for 3,354 people at a time when community staff consist of 3,972 officers and midwives are underrepresented (just 219). As regards distribution, specialized doctors and nurses are found more in hospitals and the Metropolitan Area, whereas community staff mainly work in health clinics and health centers without beds within the public sector.
The Government should strengthen efforts towards primary care since its prioritization would help achieve Universal Health Coverage (UHC) and extend access to essential health services for the most vulnerable and poorest population groups, while reducing out-of-pocket payments.
Actually, this is a very hard task because of internal and external financial and political constraints. Nonetheless, guidelines released by WHO and the World Bank are on the floor for implementation and proper allocation of financial resources.
Regrettably, while guidelines get significance only when linking to political commitment, in today’s Haitian context the political will looks like something that still needs to grow up.