Recovery and Health Care in Haiti
The credibility of any government is determined in large part by its capacity and willingness to provide basic services. Health care can bring people together when there is equal access, or divide people when there is not. Before and after the earthquake, quality health care in Haiti was/is primarily provided by non-governmental and international organizations (NGOs/IOs). The NGOs and IOs have been instrumental in keeping disease outbreaks at bay and access to health care for many residents in Port au Prince, at least for now, is better than it was before the earthquake. While significant accomplishments, much more remains to be done before we can say that the health care system is truly being reconstructed.
Even prior to the earthquake, the health care situation was poor (health statistics are available at the WHO and UNICEF websites.) Health care services were provided by the private sector (for those who could afford it) or NGOs (for those who could not). The Ministry of Public Health and Population (Ministère de la Santé Publique et de la Population), or MSPP, has generally been regarded as one of the more accountable Ministries, but is short on resources and capacity. Then and now, one would be hard pressed to find a government health care facility in Haiti that is consistently well-stocked, well-staffed, and well managed. Many of the best hospitals in Haiti are run by non-governmental organizations. These include the Partners in Health (PIH) facilities on the Central Plateau, the Albert Schweitzer Hospital in Deschapelles and the Comité de Bienfaisance (CBP) Hospital in Pignon. Haitians along the border frequently access health care in the Dominican Republic. In the days and weeks after the earthquake, Dominicans supported Haitian health care facilities and set up referral systems to treat the severely injured in Dominican hospitals. Their solidarity saved many lives.
Many of the NGOs already present in Haiti, such as PIH and Project Medishare, expanded operations into Port au Prince in the days after the earthquake. The International Federation of Red Cross and Red Crescent Societies (IFRC), of which the Haitian Red Cross is a part, ramped up operations with support from societies around the world including Canada, Chile, Colombia, Cuba, Finland, France, Germany, Iran, Israel, Japan, Mexico, Norway, Qatar, Republic of Korea, Spain, Sweden, Turkey, the United States and many others. Emergency response is not without irony as the Iranian and Israeli tents were established across from each other. Together, the Societies treated more than 135,000 people in the six months after the earthquake. The American Red Cross has also been very active in the health sector. It took the unusual step of providing direct budget support to pay the salaries of over 1,800 doctors, nurses, and other staff in the largest general hospital in Port au Prince, all of whom had been without pay since the earthquake.
When the Cluster Approach was called, the WHO/Pan American Health Organization (PAHO) and MSPP became responsible for coordinating health actors. Many organizations that responded were new to both Haiti and the Cluster Approach which made coordination difficult. The more experienced NGOs participated in the Health Cluster, shared information with its members, and tried to support the MSPP's mandate. For example, The United Nations Childrens Fund (UNICEF), WHO/PAHO, and the U.S. Centers for Disease Control and Prevention (CDC) worked with the MSPP to develop a minimum package of health services for the camps and re-established disease surveillance systems. The MSPP, WHO/PAHO, UNICEF, and the Haitian Red Cross jointly launched an emergency vaccination campaign that reached more than 150,000 people and was instrumental in preventing outbreaks of infectious diseases such as measles. Many earthquake survivors have lost limbs. The MSSP and partners are supporting seven orthopedic workshops for the fabrication of prosthesis. Handicap International also established 12 satellite sites providing rehabilitation services and the Cuban Medical Brigade (La Brigada) is working with 20 hospitals to provide rehabilitation services as well.
Haiti does have a health related success it can build upon, being one of only a small number of countries to reverse its HIV/AIDS epidemic. Political will, an engaged civil society, and generous support made possible through the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) helped to make this possible. Models for HIV/AIDS treatment in low resource settings developed in Haiti, have been replicated throughout the developing world. Sadly, the earthquake disrupted the infrastructure for both HIV/AIDS and broader health services. According to the Joint United Nations Program on HIV/AIDS (UNAIDS), the region around Port au Prince used to house 55 percent of national treatment sites, 49 percent of prevention of mother-to-child transmission sites, and 66 percent of newly diagnosed tuberculosis patients. UNAIDS states the priorities for restoring HIV/AIDS prevention, treatment, and care services in Haiti are to: (1) Rebuild health systems; (2) protect displaced people from HIV, (3) rebuild the national network of people living with HIV, (4) support social protection measures; (5) revitalize HIV prevention programs; and (6) re-establish coordination mechanisms for the AIDS response, and (7) develop a comprehensive monitoring and evaluation mechanism.
What does it take to build a health care system? According to the WHO, all health systems have six basic building blocks:
1) Service Delivery: Effective provision of health interventions to people needing them, with a minimum waste of resources.
2) Health Workforce: Adequately trained and equipped health workers that provide fair and equitable access to needed services.
3) Financing: Adequately funded health systems that ensure service delivery and protect systems from financial disaster.
4) Medical Products and Technologies: Equitable access to safe, effective and affordable drugs, supplies, tools and other products.
5) Health Information System: Production, analysis, dissemination, and use of reliable and timely information on health determinants, health systems and health status.
6) Leadership and Governance: Institutes strategic, integrated policy frameworks; sets monitoring, regulative and accountability measures; and designs and coordinates coalitions and systems.
A strengthened MSPP is needed to produce coordinated, tangible, sustainable results in each of these six areas. To be fair, the MSPP is trying, for example by asking NGOs to provide health care services through existing public or private health care facilities. Shifting services from the camps to neighboring communities is a key step in moving from emergency response to development of systems. Due to long-standing issues with efficiency and accountable, most NGOs have shied away from working with government health care facilities. There are exceptions. Konbit Sante, a small NGO in Cap Haitian, works closely with the Justinian Hospital, the largest public facility in the north, to build its physical infrastructure and the capacity of its staff. In this way, Konbit Sante supports the MSPP instead of the other way around. This sort of partnership, if replicated with in Port au Prince and elsewhere with NGOs and universities, could promote a transition from emergency response to sustainable development. This will not happen overnight and transition is not just a question of resources. It is also an issue of reform. The MSPP can show leadership by devolving authority to governmental health care facilities in the provinces so they can better manage their own operations. As is, public hospitals receive financial support from the central government infrequently which makes budgeting extremely difficult. Hospitals in the provinces also require high-level clearance from Port au Prince to high and fire staff, which makes management a major challenge. A high absenteeism is not uncommon given that staff know they are unlikely or unable to be fired unless authorities in Port au Prince signs off on it.
In the short to medium term, health services will continue to be delivered by NGOs, many of which are attempting to balance the challenge of meeting the needs of earthquake victims in Port au Prince and the greater south with victims of abject poverty in rural areas. There are ways to accomplish both. On July 3rd, PIH broke ground on a new teaching hospital in Mirebalais which is less than an hour outside of Port au Prince on a paved road. PIH anticipates that by January 12, 2011 the seven buildings of the main hospital campus will be constructed, and the work on the interiors can begin. The hospital should begin accepting patients by the end of 2011. The new hospital will have 320 beds and will integrate research, training, and service. The Haitian Minister of Health has said, “What Haiti needs now are true partners to help us build back better by strengthening our country's public infrastructure. The new teaching hospital at Mirebalais will be a model for our national health system, offering high-quality medical services, a place for our clinicians to study and train, and hope and dignity to all who will seek—and offer—care there."
Other governments are engaging the Haitian government on health issues. The U.S. Centers for Disease Control and Prevention (CDC) is developing a long-term strategy for building the capacity of the MSPP. Cuba has long provided staff and training to the MSPP and significantly ramped up their operations after the earthquake. Brazil and the United Nations Development Program (UNDP) signed an agreement to strengthen tracking of infectious diseases. These governments will accomplish more by developing joint plans and working together over the long term. My concern is that as time goes on, and major disasters occur elsewhere, attention from other governments will fade. Time to finalize those work-plans.
Public health also depends upon progress in other areas as well. The health of women and children depends in part on developing a culture that values human rights and a government that enforces them. Gender based violence was a serious human rights challenge prior to the earthquake, and it is remains one today. Concerning reproductive health, the MSPP has a national policy for free obstetric care in public health facilities although emergency obstetric and newborn care are limited in terms of quality and availability. The United Nations Population Fund (UNFPA) has been working with the MSPP and NGO/IO partners to support reproductive health services. For example, UNFPA ordered and distributed 7 million male condoms in the earthquake-affected areas. For more information on reproductive health in Haiti, take a look at a repor that the Women’s Refugee Commission released on that subject in May. Another issue central to public health is nutrition. Malnutrition weakens the immune systems and cognitive development of children. Water, Sanitation, and Hygiene (WASH) is also fundamental to protecting the health of children. Issues to be addressed in future blogs.
What would it take to move Haiti's health system further from emergency response and closer to development? Any sustainable strategy will require building the capacity of the MSPP. It should be supported with secondments from partner governments and international organizations so that it can plan, prioritize, and organize the hundreds of organizations, public and private, providing health care services in Haiti. A great many short term medical missions take place to Haiti each year, but they are more useful for training the foreign health care providers than for the delivery of services to Haitians. Instead, The MSPP could develop formal programs to attract Haitian health care providers in the Diaspora, of which there are many, back to Haiti for months, years, or a career. Health care providers from other countries in Latin America and the Caribbean may also be willing to participate. The MSPP should continue encouraging the NGOs to partner with fixed health care facilities, not just in Port au Prince but also throughout the country. If the MSPP can commit to equipping and predictably financing government health care facilities, NGOs will be more likely to enter into long term partnerships where they help Haitians manage their own health care facilities.
Interested in learning more about health in Haiti? Take a look at the Haiti Resource Finder to view over 1,300 health care facilities throughout Haiti. There is also a google group for discussing the listings on the Haiti Resource Finder. The Interaction Haiti Aid Map is another good resource you can use to search for organizations active in the health sector. More information also avaliable at Relief Web and the One Response Haiti page. Take a look at the websites of NGOs active in the health sectors such as the International Medical Corps, the International Rescue Committee, Partners in Health, Mercy Corps, and Interaction (an advocacy organization that represents U.S. based NGOs working on development and humanitarian assistance.)
Haitians deserve a better health care system. The earthquake has provided an opportunity to think critically about how best this can be accomplished over the long term. Please feel free to post your thoughts in the comments section below.