The Long Wait: Reproductive Health Care in Haiti

JSI Research & Training Institute, Inc. is a health research/consulting firm dedicated to improving the health of individuals and communities worldwide.  JSI visited Haiti in January 2009 to identify gaps in the availability and accessibility of reproductive health (RH) services and to assess community responses for strengthening quality, accessibility and availability.  Reproductive health is a social issue, a public health issue, a human rights issue, a security issue, and one that is important for countries that are fragile, stable, or in Haiti's case, teetering in between.  The report is attached and deserves to be widely read.

To give a sense of the status of RH in Haiti, the report notes that:

• The average life expectancy of a Haitian woman is 62.8 years as compared to 75.5 years in the Dominican Republic and 80.8 years in the United States.

• The maternal mortality ratio (maternal deaths per every 100,000 births) is 630/100,000 live births in Haiti as compared to 150/100,000 live births in the Dominican Republic and 14/100,000 in the United States.

• The infant mortality rate (deaths of children under one year of age per 1,000 live births) is 57/1,000 in Haiti as compared to 31/1,000 in the Dominican Republic and 7/1,000 in the United Sates.

• The average fertility rate is 4.79 children in Haiti as compared to 2.8 children in the Dominican Republic and 2.1 in the United States. Note: Contraception usage has significantly decreased between the 1990s and today.

• 37.5% of women between the age of 15-49 who would use family planning do not have access to it, as compared to only 11% in the Dominican Republic.

• 26.1% of births in Haiti are attended to by trained personnel, as compared to 98% in the Dominican Republic and 99% in the United States.  

You don't have to be a statistician to see that the current state of reproductive health in Haiti is unacceptable.  The Haitian Ministry of Health (MoH), which has some very good staff but is chronically under-resourced, recognizes that there are many critical RH related needs.  The MoH does have a reproductive health strategy, which prioritizes reducing the country's alarming maternal mortality, more on par with Sub-Sahara Africa than Latin American and the Caribbean.  

As part of this strategy, Canada, through its Canadian International Development Agency (CIDA), is financing a maternal mortality reduction program in the North.  France, through its Agence Francaise de Developpement (AFD), supports a similar program in the South.  Canada also supports a free obstetric care program to encourage Haitian mothers to give birth in facilities rather than at home.  

USAID supports a family planning program to strengthen quality, supply management systems, and counseling in 152 of Haiti’s existing 752 health service delivery sites.  Prevention of Mother to Child Transmission (PMTCT) of HIV, is offered in 93 sites with support from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the United Nations Children's Fund (UNICEF).  Clinics have been upgraded for improved prenatal care and a number of government maternities were rehabilitated.

The Cuban government has long loaned health care professionals to Haiti who provide a range of generalist and specialist services critical for safer motherhood.  Haitian medical students are also trained in Cuba.  If you've seen a pregnant mother have complications while delivering, knowing there are no health care providers nearby, you understand what a frightening ane helpless feeling it is.  In Haiti, sadly, it is all too common.

Donor support is welcome given Haiti's lack of resources.  However, having an agenda that is donor driven and a health care system where NGOs deliver most health services makes it difficuly for the government to address gap issues.  While Haiti has over 450 NGOs, JSI notes that availability of services is uneven, inadequate and short-term.  There is an over-reliance on NGOs for reproductive health services because their facilities are better staffed and able to provide free (or mostly free) services, which understandably attracts a larger caseload.  

The report goes on to describe not unfounded expectations of poor care in public facilities as a result of frequent healthcare worker strikes, a general shortage of healthcare workers, long wait times, a lack of supplies or supplementary materials such as gloves and syringes and even a lack of space, so much so that women may have to lie on the floor as they await a health care provider.  Many NGOs will come and go but the Ministry of Health will always be there - coordination with, and building the capacity of, the Haitian government to meet the reproductive health needs of its citizens is key to sustainability.

It is alarming that contraception use has decreased over time.  Needless to say, Haiti is a country of limited resources.  Population growth has exacerbated environmental degradation, making it more difficult for a family to feed itself.  Decreasing population growth would mean less pressure on the educational and health systems.  Haitian women need the ability to determine how many children they want to have.  Fewer women would be at risk of dieing in a country where birth remains a life-threatening event.  Smaller families would mean far fewer restaveks, fewer children exploited by the sex trade, and less street children.  It would also slow the flow of Haitians from rural areas into urban centers in search of livelihoods. 

Access to information and contraception is much lower in rural areas than in urban areas.  This is significant as most of Haiti's population lives in rural areas.  FOSREF, a Haitian NGO specializing in youth friendly reproductive health services, reports they provide 25% of family planning services in Haiti, mostly to urban areas.  JSI found that many Haitian families living near the border with the Dominican Republic cross over to access supplies and services.  Other than FOSREF, the only other NGO (to my knowledge) that engages in social marketing for contraception  throughout the country is Population Services International.

The report makes clear that, for all aspects of reproductive health, there are local organizations who, with increased capacity and resources, could scale up their activities.   For example, URAMEL (Unité de Recherche et d’Action Médico Légale) is a Haitian organization that has been instrumental in strengthening Haiti’s response to violence against women.  URAMEL provides training for case management of survivors of gender based violence and plays a lead role in national coordination efforts. 

Below is a summary of the key findings and recommendations:

Findings

1) Comprehensive RH care in Haiti remains generally inadequate even during the nonemergency period, despite the reproductive health services provided by relatively well resourced emergency NGOs in limited locations.

2) Family planning (FP) access in Haiti is particularly lacking.  Since the 1970s, FP has been inconsistently supported.  Today, challenges persist: unmet need is high, and commodities are urgently needed, especially in light of a broken supply chain system; access to quality services remains inadequate for the demand; remote areas have a limited availability of methods, especially long-term methods; and geographic gaps are scattered throughout the country.  In particular, quality adolescent family planning services are insufficient to meet the need in many areas. 

3) A fine balance between building local capacity and providing quality services has been hard to strike in Haiti where investments in the public health system and Haitian NGOs are often relinquished for funding allocations to international NGOs that provided needed quality RH services during crisis.

4) A number of promising Haitian organizations that provide RH-related services are well in-tune with the community’s needs.  These local NGOs often address RH needs in the way women experience them, holistically. While these organizations operate on relatively small budgets, many of these groups are often overlooked by donors in favor of familiar international NGOs with large-scale funding requirements and quick-impact programming. 

5) Indirect costs such as transportation expenses, long periods of waiting, and poor or absent care due to health worker shortages and strikes inhibit many women from accessing free services.  Free services, especially those related to safer motherhood and emergency obstetric care, contribute to the Ministry of Health’s priority to reduce the maternal mortality rate.  However, reaching women, especially those who cannot afford these indirect costs, has been difficult.

Recommendations

• Allocate more funding for Reproductive Health services before, during, and after Emergencies: Donors and the Haitian government should increase the pool of available funds to cover all areas of reproductive health, especially family planning which has been inadequate in rural areas and during times of crisis.  Funding should be sustained after crises to ensure continuity in services.

• Adapt Better Funding Mechanisms: Existing funding structures should adapt to bridge the service and funding gap in reproductive health between relief and development.  Short-term funding, largely given to international NGOs, undermines long-term development capacity building.  Better coordination among not only donors, but also relief and development actors is necessary in order to strike a balance between providing essential, quality services and strengthening the framework for long-term development programs.

• Support Local Leadership for a Coordinated Response: The international community should prioritize financial and political support for local NGOs and Haitian government public health officials to lead a coordinated, comprehensive model that addresses crisis and development.  More investment should be made in local capacity and the Haitian public health budget in order to meet ongoing public health demands before, during, and after a crisis.

• Make Community Level Investments: More investments at the community level should be made to reduce the unsustainable burden on general hospitals.  Some of the most effective organizations are Haitian NGOs that operate on relatively small budgets and are well-positioned to address primary healthcare needs, thus alleviating the stress on tertiary care facilities.  Because local groups are well in-tune with the community, they address reproductive health needs in the way that women themselves experience them, holistically.  Haitian NGOs are not easily defined as HIV or family planning organizations or compartmentalized as relief or development actors.  These organizations are often overlooked in favor of short-term, large-scale funding for international NGOs.  Because local actors are often first responders,  they are well-placed to provide the Minimal Initial Service Package (MISP) for reproductive health in crisis situations, and also remain long after a crisis to provide continuity in services for the community.  These invaluable human resources should neither be overlooked in times of crisis nor beyond.

• Support Holistic, Integrated Models for Comprehensive RH: More investments in funding and training should be made in family planning and adolescent sexual and reproductive health.  These two components are not as well resourced as HIV, safer motherhood, and gender-based violence.  Failure to unite the piecemeal approach will likely result in continued service gaps and mortality.  Comprehensive reproductive health can build on the coordination and service infrastructure of initiatives that have succeeded, like HIV prevention.  Better integration of the issues that face Haitian women provides an opportunity to close the gaps not only in reproductive health services, but also in economic disparities.

Greater attention, commitment, and investments in reproductive health, especially to build the capacity of local actors, would help bring about the quality, access and availability of reproductive health services that the country deserves.  I hope to see reproductive health become more of a shared priority for the Haitian government and its partners.

Interested in learning more about this report or JSI's activities in Haiti?  Contact information for the assessment team is below.  Thanks!

Molly Fitzgerald

JSI Research & Training Institute, Inc.

Telephone: +1.703.310.5072

Email: mfitzgerald@jsi.com

Erika Larson

JSI Research & Training Institute, Inc.

Telephone: +1.703.310.5286

Email: elarson@jsi.com