HUEH is the largest hospital in Haiti and, prior to the earthquake, treated over 169,000 patients a year. Located in Port-au-Prince, HUEH (Haiti’s University and Educational Hospital) now has a catchment population of approximately 500,000 people, many who have been left vulnerable and at-risk by the earthquake.
Health in Haiti
Health indicators in this poor island nation have long been dismal. Haiti has the highest infant mortality in the western hemisphere at 57 deaths/1000 live births-causes of which include neonatal mortality, acute respiratory infections, diarrhea, anaemia, and chronic malnutrition. Maternal mortality remains among the highest in the world at 630 death/100,000 births due to only 25% of births taking place in a medical facility. Only 18% of women of childbearing age have access to modern contraceptive methods. HIV/AIDS, with a prevalence rate of 2.2%, and Tuberculosis, with a detection rate of 70%, continue to represent a serious threat to public health in Haiti.
Haiti’s country-wide health system provides formal care to only 47% of the population. This reduced access is partially offset by the use of traditional medicine as a first response against disease. The private sector is extremely important, particularly non-profit providers, though its communication with the pubic sector needs to be improved. This system is structured into three levels:
First Level: 600 first-response health centers (SSPE) both with and without beds and 45 secondary community health centers (HCR);
Second Level: 10 district hospitals;
Third Level: 6 university hospitals, of which 5 are located in Port-au-Prince.
It should be noted that many of these health centers are managed by either non-governmental organizations (NGOs) or by faith-based organizations (FBOs). The formal network is theoretically organized into 54 municipal health units (MHUs), each serving a population of 80,000 to 140,000 local residents.The MHUs have been mandated to ensure the provision of a minimum package of services and coordinate the primary health care network.
In practice, the Haitian health system has major problems with functionality at both the micro and macro level, resulting in a care package which is often fragmented, inaccessible, and with low quality control. Since 2000, the health system has built 5 high-tech diagnostic centers but despite their intended role as a bridge between the first and second levels of the health system, these centers remain poorly integrated with the rest of the system.
Finally, a private, for-profit system covers a small proportion of the population which operates outside of the control of the public health system. In Haiti there are 3 private laboratories producing drugs but covering only a small share of the market.
Major Deficits in the Haitian Public Health System
Low coverage rates and significant inequities:
Although the minimum package of services was redefined in 2006, it remains hard to access: 47% of the population lacks access to health care primarily due to financial or geographic barriers, and 50% of households said they had not accessed health services when needed because of the high costs associated with services. Only 25% of women deliver in institutions, with 78.2% of women in the richest quintile delivering in health centers versus 5.9% of women in the poorest quintile. In urban areas, around 90% of people live within 30 minutes of a health institution, while around 50% of residents in rural areas walk 30 minutes or more to reach their nearest health center. The quality of community health services is very low, and public participation in their functioning is extremely limited. Motorized transport in rural areas is almost non-existent.
Low level of funding and inefficiencies:
With 5.7% of GDP spent on health in 2005-06 and $32 USD per capita spent each year (MPPH, 2009), Haiti should have better health outcomes. However, as health costs most frequently come from the patients or their relatives, they are left little recourse if their health condition requires treatment exceeding their ability to pay. Additionally, ¾ of the population survives on less thatn $2 USD per day (UNDP, 2005), which, with Haiti’s cost recovery system, can turn a seemingly low cost health service into an insurmountable obstacle.
Furthermore, the importance of the international cooperational funds in health financing also poses serious difficulties in terms of the fragmentation of the system. For example, expenses for HIV/AIDS are equal to twice the entire public budget devoted to health. In addition, several programs in the field of HIV/AIDS and other international funding are designed completely vertically in order to show immediate and visible results, and this fact leads to an imbalance in amounts of support provided to different services. This situation is far from a lasting solution to the overal health problems of the population and weakens the leadership of the MPPH.
Finally, the state takes nearly one third of health spending in overhead costs. Overall, the budget allocated to the health sector for fiscal year 2009-10 was $7.5M USD, of which a large proportion (80%) goes to paying staff salaries.
Lack of governance and coordination:
With the large number of actors and stakeholders in the public health sector, it is very difficult for the national health authority (MPPH) to provide leadership, coordination, management and an appropriate regulation system. The core functions of public health are only tentatively assumed and the national information system remains inefficient due to the heterogeneity of the many parallel systems related to specific projects which are frequently implemented without any coordination with the MPPH.
Decentralization and organizational dysfunction:
There is no clear national policy on decentralization, and the health system remains highly centralized. The roles and responsibilities between the levels are poorly defined and frequently overlap each other.
Lack of human resources and low productivity:
With an average of 5.9 doctors and nurses per 10,000 inhabitants and 6.5 health workers per 10 000 inhabitants, Haiti is far from the WHO minimum standard of 25 professionals to 10,000 residents.The development of human resources is further aggravated by a certain slowness in the system of accreditation for many private schools training health professionals and a lack of strategic planning for human resource requirements especially in regard to a genuine policy for staff retention in an environment strongly influenced by the attraction exerted by the private sector and NGOs that offer opportunities such as a more attractive salary.
The presence of human resources is not synonymous with quality health services. The reasons for low productivity are many: low salaries, lack of career paths, harsh working and living conditions and no mechanisms for monitoring performance. Finally, the absence of an accreditation system for the many private schools and implementation of curricula which do not match the needs of the health systems also have a negative impact on development, performance and retention of staff.
Blood Transfusions, with the National Program for Blood Safety (NPBS):
The NPBS, which started offering the safest blood in all hospitals in the country due to strong technical and financial support from the ministry, was also affected by the earthquake as the main office has collapsed and two other centers were damaged.
Following the earthquake, there was a slowdown of operations at the blood collection facilities, effecting the solicitation, collection and distribution of blood. Even if the district hospitals with transfusion posts onsite were not affected physically, the migration which followed the earthquake resulted in an unmet increase in demand for blood due to the large number of earthquake victims needing surgery.
Impact of the January 12 Earthquake
The effects of the earthquake on the health sector structures were catastrophic. Within the 3 geographical departments most affected (West, South East and Nippes), 60% of hospitals were severely damaged or completely destroyed. The offices and management facilitiesof the department of health have also been badly affects – the department’s main building has completely collapsed.
The displacement of approximately 1.2 million people has greatly increased the pressure on the health care system in the geographical departments not directly affected by the earthquake, making the disaster a national issue. Thousands of people were injured, and more than 4,000 amputations were performed.
New vulnerable groups have appeared due to newly limited functionning after amputation or psychological trauma related to the earthquake. In the coming months, if nothing is done, there is an increased risk of malutrition among the most vulnerable, high mortality rates among children under 5 years and an increase in maternal mortality related to the reduced availability of obstetric care.
The impact of the crisis will continue to be felt for many years, firstly because of the expected risk of epidemics related to poor housing conditions for a portion of the population, and secondly due to the increase in poverty resulting from the reduction of economic activities. The disruption of health services caused by the demobilization of health personnel affected by the earthquake also contributes to the negative impacts in terms of reducing the volume of services. The effectiveness of the Department of Population and Public Health has been reduced (coordination, staff, infrastructure, equipment). While increasing the accessibility of care, the arrival of many new actors has posed additional challenges to the already very weak coordination of the health sector.