GENERAL SITUATION AND TRENDS
Socioeconomic, Political, and Demographic Overview
The Republic of Haiti occupies the western third of the Island of Hispaniola, which it shares with the Dominican Republic. The country is divided into nine departments ("départements"), 133 municipalities ("communes"), and 561 districts ("sections communales").
Water supply and basic sanitation services are still very deficient. No city has a public sewerage system, and there only are isolated wastewater treatment units throughout the country. Solid waste management is a serious problem; bad excreta disposal practices are polluting almost all 18 water sources supplying Port-au-Prince. The growing number of motor vehicles and their inadequate maintenance have created a serious air pollution problem in Port-au-Prince.
Every year, approximately 20,000 tons of arable land are lost to the sea due to deforestation and erosion. This phenomenon is aggravated by charcoal production throughout the countryside and heavy agricultural pressure on steep slopes.
The major trends in the Haitian economy over the past decade indicate a steady decline in the actual gross domestic product and a net rise in unemployment. Economic sanctions that were imposed in 1991 further deteriorated the economy. The gross domestic product in 1994 had decreased back to its pre-1980 level. This was paralleled by a population growth rate of 2.1% and a steep decline in per capita income from 1990 to 1995. The 4.2% growth rate in GDP reported for 19941995 could not offset that indicators 25% decrease during the embargo (19911994), thus maintaining Haitis position as the poorest country in the Western Hemisphere. According to World Bank figures, per capita GDP was US$ 220 in 1994, equivalent to US$ 896 adjusted according to purchase power parity (PPP), making it one of the lowest in the world.
The inflation rate averaged 25.4% between 1991 and 1994 and rose to 27% in 1995. The unemployment rate is estimated at 70%.
Population projections, developed by the Haitian Institute for Statistics and Information Technology in conjunction with the Latin American Demographic Center, estimated the population of Haiti at 7,180,296 inhabitants in 1995. Persons younger than 15 years of age account for 40% of the total population; children under 5 years of age account for 15%. Persons of working age, between the ages of 15 and 64 years, represented 56% of the population. The population aged 65 years old and older accounted for only 4% of the total.
Projections for 19952000 place the crude birth rate at 34.1 per 1,000 and the crude death rate at 10.72 per 1,000. The fertility rate was estimated at 4.8 children per woman. Based on these estimates and an anticipated population growth rate of 2% per year, it was estimated that the population will reach 8 million by the year 2000. Haiti has one of the highest population densities of all Latin American countries, with 260 inhabitants per km2 as of 1995 and 885 inhabitants per km2 of cultivated land.
The percentage of urban population in 1994 was 33%, the lowest in the Hemisphere. However, it has increased in recent years with rapid proliferation of shantytowns in Haitian cities (Le Cap-Haïtien, Gonaïves, Les Cayes). More than one-third of the total population (34.7%) lives in the capital, Port-au-Prince. The rural exodus has overburdened the housing situation, particularly in Port-au-Prince. Haphazard housing construction resulted in the erection of many dwellings in drainage areas, river beds, and protected water resource developments.
There were major migratory movements between 1991 and 1994. Internal migration to the countryside occurred after the coup in September 1991, with approximately 200,000 persons fleeing Port-au-Prince to take refuge in rural areas. Since 1995, there has been an increase in internal migration back to Port-au-Prince, accompanied by a decline in illegal migration. The number of Haitians living abroad is estimated at more than 2,000,000, mainly in the USA, Canada, France, and the Dominican Republic.
There is no systematic method to collect, process, and disseminate information on mortality. Nearly one-half of all deaths occur within the first 5 years of life. According to a survey on morbidity, mortality, and use of services conducted by the Child Health Institute in 19941995 (EMMUS-II), 74 out of each 1,000 live births die before their first birthday, and approximately 131 never reach their fifth birthday. In 1987, an earlier study (EMMUS-I) put infant mortality at 101 deaths per 1,000 live births.
There has been a steady improvement in net enrollment ratios at the primary school level over the past decade. Enrollment climbed from 37.2% to 44.1% between 1988 and 1991, and the estimate for 1995 is 51.4%, with similar values for males and females, but this has been accompanied by a shrinkage in the average size of school facilities and the growing numbers of poor-quality schools and overcrowding. School attendance by lower income children is limited by the cost of school fees and curtailed by child labor.
French and Creole are the two official languages, but Creole is the everyday language used by all segments of society.
The individual perception of illness in Haiti is grounded in a highly complex cultural heritage. There are various types of traditional healers, including spiritual healers. Improper feeding practices have important deleterious effects on health (e.g., administration of purgatives to newborns during the first days after birth and feeding newborns with porridge or solid foods). Forty-two percent of newborns are bottle-fed within the first month; it is estimated that less than 1% of children are completely breast-fed by 6 months of age.
SPECIFIC HEALTH PROBLEMS
Analysis by Population Group
Health of Children
The leading causes of child mortality in Haiti are diarrheal diseases, acute respiratory infections, and malnutrition. Major causes of hospitalization for children 014 years old in 1995 were prematurity (23%), pneumonia (16%), malnutrition (8%), meningitis (8%), typhoid (6%), and gastroenteritis (5%).
In 1991, the Center for Research on Human Resources conducted a survey in three cities in three different departments. The survey provided an overview of the plight of children (boys and girls under 18 years of age) in especially difficult circumstances, including several groups: children employed as domestics, abandoned children, orphans, incarcerated juvenile offenders, child prostitutes (male and female), abused children, and street children.
In 1991, the number of street children in Haiti ranged from 1,500 to 2,000 in Port-au-Prince. Most of them are boys, but the number of girls appears to be increasing, accounting for 18% of the children surveyed. The mean age of these children is about 11 years; 55% of them are aged 12 to 18 years old, and 14% are 5 years old or less. They are particularly vulnerable to tuberculosis, anemia, skin diseases, and sexually transmitted diseases. Many of these children are drug users (53% of the inner-city sample).
Health of Adolescents (Age Groups 1014 and 1519 Years Old)
A study conducted in 1992 in Cité Soleil (the main slum of the capital) by the Research, Culture, Health and Sexuality Team revealed that many young residents were sexually active by 13 years of age. The use of contraceptives is extremely rare within this age group. According to data from EMMUS-II, only 4.4% of those who were sexually active at the time of the survey had used a modern method of contraception, and 8 % of all births were to teenage mothers aged 15 to 19 years of age.
Adolescents accounted for 15% of birth-related deaths, and nearly 4% of them had induced abortions with rates higher in the cities than rural areas. Between 1991 and 1992, the Child Health Institute conducted a seroprevalence study of post-partum HIV-1 infected women, which revealed that 7.4 % was seropositive for HIV in metropolitan areas, and 4.1% in rural or semirural areas. Typhoid accounted for some 64% of admissions to the Haitian State University Hospital pediatrics ward of children aged 914, and meningococcemia accounted for 28%.
Health of Women
Women accounted for roughly half of the total population (51%). In the field of education, girls and boys have equal opportunities to attend primary school. At the primary school level the gross number of years of schooling for girls is 0.52.1 years lower than for boys. Women also enter the job market at an early age; roughly 10% of young girls aged 59 years and 33% of girls aged 1014 may be considered economically active.
Because of food insecurity and short intervals between births, chronic malnutrition, including anemia, was widespread among women of childbearing age. The main indicators include high prevalence of low birthweight (estimated at 15%), of anemia among women (ranging from 35 % to 50%), of body mass index under 18.5 kg/m2 (estimated at 18%), and of high maternal mortality rate (estimated at 456 per 100,000 live births).
In 1995, a national study on violence against women was. From a sample of 14 municipalities, out of a total of 133, a total of 1,935 cases of violence were reported: violence was classified as physical (33%); sexual (37%), with rape representing 13% of the total; others (6%); and unspecified (25%). The 81% of all documented cases of violence involved women aged 1034.
According to a study conducted by the Albert Schweitzer Hospital, the cervical cancer is the most common form of cancer. Women are increasingly victims of HIV infection; 53 % of female partners of infected males are HIV carriers.
For the 19901995 period, life expectancy in Haiti was estimated at 58.3 years for women and 54.9 for men. The general fertility rate is 4.8 children per woman for women aged 1549 years old. Most women indicated that they wanted to give birth to only three children.
Some 71% of the female respondents interviewed during EMMUS-II reported having been attended by a professional or a traditional birth attendant during childbirth. Of the women interviewed, 80% had given birth to their last child at home. Fifty percent of women living in Port-au-Prince generally give birth in a hospital, compared with only 31% of births in other urban areas and 9% of births in rural areas. The leading causes of maternal deaths are: obstructed labor (8.3%), toxemia (16.7%), and hemorrhage (8.3%). The high maternal mortality rate is mainly the result of inadequate prenatal care.
According to EMMUS-II, an estimated 68% of pregnant women had at least one prenatal examination by a health care professional and 66% received at least one dose of tetanus vaccine. Among pregnant women, 34% had four or more prenatal examinations, 26% had 23 examinations, and 8% had only one examination.
The most popular methods of contraception were the birth control pill, female sterilization, injections, and condoms (3% each). Among sexually active women, 13% used a modern method of contraception and 4% relied on traditional methods. Among sexually active men, 17% used a modern method (6% used condoms) and 16% relied on traditional methods.
Analysis by Type of Disease or Health Impairment
Vector-Borne Diseases. Malaria is considered a public health problem in Haiti, especially in rural areas. Plasmodium falciparum is prevalent throughout the country. The last confirmed indigenous cases of Plasmodium vivax infection occurred in 1983. Most cases of malaria transmission occur in coastal areas at altitudes below 300 m, particularly in the heavily populated rice-growing areas in the south and Artibonite. Estimates made in 1988, as part of an effort to map out a strategy for malaria control, amounted to 250,000 annual malaria cases, with a 1% case fatality rate. Slide positivity indexes for the 19911994 period are unusually high, ranging from 31.2% to 42%.
Dengue is considered an endemic disease. The Aedes aegypti, is found throughout the country, and extremely high infestation rates have been reported, particularly in urban areas. Data collected 10 years ago by the Department of Public Health put the seroprevalence rate at 3%. In 1994, an outbreak of dengue was reported in Port-au-Prince. Serotype 1 isolates were found in patients suffering from febrile illnesses. Serotypes 1, 2, and 4 are currently found in Haiti, while serotype 3 has never been identified.
Lymphatic filariasis, found in scattered urban foci, mainly in the north and Gulf of La Gonâve, is still a serious public health threat in Haiti. Wuchereria bancrofti, transmitted by Culex quinquefasciatus, is becoming meso-hyperendemic in coastal areas. Its effects were most visible in boys and men, who generally develop elephantiasis of the scrotum. Studies conducted by the United States Centers for Disease Control and Prevention indicate that more than 20% of the population of most coastal cities, including Léogâne, Petit-Goâve, Arcahaie, and Limbé, are carriers of the microfilaria.
Vaccine-Preventable Diseases. In August 1994, Haiti was declared free of poliomyelitis by the International Certification Commission on Polio Eradication, and since then no cases of flaccid paralysis have been confirmed as poliomyelitis. However, vaccination rates remain very low (30% in 1995).
Between 1989 and 1994, the average attack rate for measles was 24 per 100,000 persons. A countrywide measles epidemic broke out in July 1991. Since the national vaccination campaign in 19941995, no cases of measles have been confirmed. The routine vaccination rate in infants younger than 1 year old in 1995 was estimated at 75%.
Regarding neonatal tetanus, 78 cases were reported in 1995 for the whole country. During the first six months of 1997, 31 cases of neonatal tetanus were reported by 39 sentinel sites from the nine departments.
Hepatitis B surface antigen was found in 5.5% of donors tested in 1990. In 1996 serosentinel studies conducted by the Child Health Institute and GHESKIO Centers, at facilities in nine locations (one by department), found hepatitis B surface antigen in 2%7% of pregnant women.
Intestinal Infectious Diseases. There were no reported cases of cholera as of July 1997. The epidemiological surveillance system established for acute diarrhea identified Vibrio furnissii for the first time in the Caribbean and Non-01 Vibrio cholerae isolated from a stool specimen taken from a patient with cholera-like symptoms.
From 1987 to 1994, the National Health Surveys detected a sharp decline in the incidence of diarrhea in children under 5 years old (from 43% to 27.6% for the two-week period preceding the surveys); however, values remain very high, reaching 47.7% in the age group 611 months old. Diarrheal diseases are the leading cause of illness and death in children under 5 years of age, often associated with acute respiratory infections and malnutrition.
Typhoid is endemic in Haiti. In 1991, a major typhoid epidemic was confirmed in several low-income neighborhoods of Port-au-Prince. Several epidemic foci were reported in 19921993, predominantly in the south. From July to December 1995, typhoid was responsible for 6% of admissions at the Haitian State University Hospital pediatrics ward. It ranked as the fifth leading cause of hospitalization.
Chronic Communicable Diseases. Between 1981 and 1990, more than 6,000 new cases of tuberculosis were notified each year to WHO; 10,237 cases or 154.7 per 100,000 were reported in 1991, date of the last notification. The incidence of tuberculosis in Haiti is estimated at 180 per 100,000 inhabitants. The high mortality rate is the result of the countrys generalized poverty, and HIV/AIDS epidemic. In a study conducted in 19921993, an HIV seroprevalence of 19% was found in a group of 240 tuberculosis patients. Data from 1991 show that 50% of all patients with AIDS suffered from tuberculosis. Seroprevalence studies among children, conducted in 1996, confirmed the close correlation between tuberculosis and HIV infection.
Between 1977 and 1996, the countrys two referral facilities, Providence Hospital in Gonaïves (Artibonite) and the Fame Pereo Institute in Port-au-Prince, saw 1,998 registered patients, 80.5% them being paucibacillary cases and 19.5% multibacillary cases. A breakdown of leprosy patients by age group reveals that 21% were children under 15 years of age of whom 12.6% were multibacillary cases. Of 521 leprosy cases diagnosed between 1993 and 1996, 22 cases of disabilities grade 2 and over were notified.
Acute Respiratory Infections. Data produced by EMMUS-II for 1994 showed that 20% of children under 5 years of age suffered from acute respiratory infections (ARIs) during the two weeks preceding the survey. In 1994, ARIs accounted for 25% of deaths among children under 5 years of age, and pneumonia was the number one cause of death among ARI patients. In 19941995, ARIs were the leading cause of patient visits to 42 sentinel facilities in Haiti.
Rabies and Other Zoonoses. Two to four cases of human rabies were reported each year between 1990 and 1995. Only one of the cases in 1993 was confirmed by the Connecticut State Laboratory in the United States. Seven cases were reported in 1996.
Leptospirosis appeared to be on the rise. In 1995, 64 cases of the disease were identified and 32 cases were reported during the first four months of 1996. The male-to-female ratio is 2:1, with 35% of the cases involving males between the ages of 20 and 39. The disease proved fatal in 33% of the cases.
AIDS and Other Sexually Transmitted Diseases. A cumulative total of 4,967 AIDS cases (46% of whom were female) were reported between 1982 and 1992. Official reports and notification of AIDS cases were suspended by 1992. As of 1996, the percentage of the sexually active population infected with HIV was estimated at 3%5% in rural areas and 7%10% in urban areas. Preliminary projections, based on different mathematical models, conclude that the number of HIV-positive individuals will reach more than 380,760 by the year 2000 and the annual number of deaths could climb as high as 27,000, including 6,000 children. HIV transmission is predominantly heterosexual (male/female ratio 1.2:1).
Emerging and Re-emerging Diseases. In late April 1994, a meningococcemia epidemic was reported in Ouanaminthe, in the Northeast Department. By the end of November, approximately 100 cases and nine deaths had been reported. Group C Neisseria meningitidis was identified. In 1995, in the Port-au-Prince area, over 75% of the cases involved children between 5 and 14 years of age. The rest of the country also reported cases, with the largest number of cases seen in rural areas in the Artibonite. In all of 1995, 158 cases were reported, of which 55 died, yielding a case-fatality rate of 35%.
Noncommunicable Diseases and Other Health-Related Problems
Nutritional Diseases and Diseases of Metabolism. In 19941995, EMMUS-II revealed a significant increase in the prevalence of wasting since 1990, mainly affecting children under 3 years of age. More than one-third of all children who survived their first birthday showed signs of severe growth retardation.
By age 5 years, 41% of all children were severely stunted. High rates of malnutrition and infectious diseases suggest that many preschool children are suffering from the effects of vitamin A deficiency and/or nutritional anemia. Mangoes are an important dietary source of vitamin A, and following their abundant availability, a seasonal variation has been observed in the dietary intake and deficiency of vitamin A.
A 1991 survey conducted in the Central Plateau showed a prevalence rate of 10% for all types of goiter (Grades 1 + 2) and 2.5% for visible forms of goiter. Similarly, urinary iodine in the general population was 10.3 µg/dl. Iodine deficiency problems are typically confined to the isolated inland mountainous areas.
There were three types of diabetes registered in Haiti: type 1, or insulin-dependent diabetes (10% of total); type 2, or non-insulin-dependent diabetes; and type 3, or malnutrition-related diabetes ("tropical" diabetes). The prevalence ranges from 2%8% for different parts of the country. Half of all amputations performed in the State University Hospital in 1987 concerned patients with diabetes.
Cardiovascular Diseases. These diseases accounted for 40% of patient admissions at the State University Hospital in 1996, mainly cerebrovascular accidents and ischemic heart disease. Two surveys suggest a 13%15% prevalence of high blood pressure in the adult population 18 years and older.
Malignant Tumors. The National Cancer Institute statistics showed that the most frequent type of cancer treated was cervical cancer, representing 60% of the total for the period 19881990 and 40% for the period 199194. Breast cancer ranked second with 15% and 30 % respectively. Nasopharynx occupied the third position with 10%15% of the cases. The total cases of cancers treated by the institution averaged 250 per year from 1988 to 1994.
Several health care facilities are partially involved in the detection, diagnosis, treatment, and care of patients suffering from cervical cancer/dysplasia.
Accidents and Violence. Data reported by the Haitian State University Hospital for 1995 showed that a higher incidence of traffic accidents occurred in December, as compared with the rest of that year. The total annual number of dead and injured was 2,393; males were more affected than females (1.7:1). Frequent domestic accidents resulted in serious burns mainly affecting children. In addition, Haiti is regularly the scene of fires and shipping accidents, such as the Neptune tragedy in February 1993, which caused 1,500 deaths.
Natural Disasters. Tropical storm Gordon struck Haiti in November 1994, claiming 1,122 lives. It destroyed 3,550 homes, seriously damaged several water supply systems, killed thousands of livestock, and damaged vast acres of food crops. The storm affected the health services through increased demand for and redistribution of limited resources. Widespread flooding, both in rural (the south in November 1995, and the south and northwest in February 1996), as well as urban areas (beachfront areas of Port-au-Prince) caused extensive damage. Drought regularly affects the countrys northwest.
RESPONSE OF THE HEALTH SYSTEM
National Health Plans and Policies
In March 1996, the Ministry of Health introduced a health policy that recognizes a fundamental right to health and the States obligation to guarantee access to health care for all. Health sector reform was designed as part of the States decentralization effort to ensure equal access to a minimum package of services.
Health Sector Reform
The Ministry of Health defined the following priorities:
Strengthening the Ministry of Health at central and departmental levels, including developing human resources and managerial capacity; using new health financing modalities, undertaking hospital reforms, updating health legislation, reviewing the policy on essential drugs, developing the health information system, pursuing intersectorial coordination, and implementing community health units based on decentralization and community participation.
Developing primary health care aimed at delivering a minimum package of health services to the population, including comprehensive child care that targets acute respiratory infections; comprehensive health care for women with emphasis on pregnancies and reduction of maternal mortality; vaccination; access to essential drugs; prevention and control of communicable diseases; targeting emerging and re-emerging diseases such as tuberculosis, STDs, and AIDS; controlling meningococcal infections and vector-borne diseases; eradicating measles, neonatal tetanus, and leprosy; and improving medico-surgical emergencies and dental care.
Strengthening health promotion activities to encourage the population to assume responsibility for its health and adopt a healthy lifestyleprograms included health information dissemination, health education, and social mobilization, particularly in the prevention of communicable diseases, violence and accidents, school health, and pathologies linked to poor nutritional habits.
Improving environmental health, including access to potable water, food hygiene, control and disposal of excreta and atmospheric pollution as well as the prevention and mitigation of disasters.
Organization of the Health Sector
Haitis health system includes the public sector, the semi-public sector, and the private sector.
The public sector was seriously affected by the countrys political crisis, which led all foreign aid to be channeled through nongovernmental organizations (NGOs). The Ministry of Health is structured into central, departmental, and community levels. Through its central directorates and units, it sets standards. Planning, monitoring, and supervision are the responsibility of the heads of the nine sanitary departments. One-third of the countrys 663 health institutions belong to the public sector.
The semi-public or mixed sector encompasses nonprofit institutions that are supported mainly by NGOs. Staff is paid in whole or in part by the public sector, but is managed by the private sector.
In 1994 there were 49 hospitals and 61 other inpatient facilities, with an estimated 90 beds per 100,000 population. Of the countrys total health care facilities, 32% are operated by NGOs. The private, profit-making sector is comprised of physicians, dentists, and other private practice specialists who mostly work in Port-au-Prince and in private health care facilities. Public and private establishments function completely independent of one another with very little networking. Differences in access to adequate health care are further magnified by the uneven geographical distribution of centers and hospital beds.
Social security benefits are limited to formally employed people. In 1995, the Insurance Agency for Occupational Accidents, Illness, and Maternity (OFATMA), an autonomous body under the umbrella of the Ministry of Social Affairs, provided insurance coverage to 2,500 public and private firms. In 1996 it covered 60,000 workers, an increase from 40,000 covered in 1994.
The estimated per capita expenditure in health for 1995 was G15.7 (US$ 2.0); it represented a decrease compared with that of 1990, which was G24.8 (US$ 3.4). Total per capita expenditure on health reached US$ 9, representing 3.5% of GDP in 1995. According to these estimates, in 1996 the government budget represented about 16% of the total expenditure; external donor agencies, which are mostly channeled through the Ministry of Health and NGOs, 28%; NGOs, 20%; and private expenditures, 36% in 1996.
Organization of Health Regulatory Activities
Health legislation originally enacted in 1981 remains in effect, but a new legal administrative framework is being drafted.
The Ministry of Health established criteria for the operation of medical and paramedical education facilities. Two private nursing schools and 10 training facilities for auxiliary nurses obtained operating licenses. The Ministrys pharmacy service issues a certificate to pharmacy students after completion of a four-year training program with a one-year internship.
The pharmacy service regulates all matters related to pharmaceuticals, which mainly involves the inspection of private pharmacies. Haiti has no drug registration, control of drug imports, or inspections of drug manufacturers. Drugs that normally required prescriptions are easily accessible and commonly sold by street vendors.
Between November 1995 and June 1996, an outbreak of acute renal failure affected 100 children, and the majority died. A multiagency investigation revealed that the condition was due do the ingestion of a locally produced acetaminophen syrup contaminated with imported diethylen glycol. To address the situation, the Ministry of Health endeavored to improve quality control monitoring through regular inspection of manufacturers, importers, suppliers, and pharmacies. Because there was no national quality control laboratory, all samples had to be sent abroad for analysis.
In November 1995, the Ministry of the Environment elaborated the National Action Plan of Environment, designed to deal with various environmental threats to freshwater, seawater, air, and soil.
Organization of Services for Care of the Population
Health Promotion and Social Communication in Health. Several large-scale, public awareness campaigns involving various sectors were launched, some of which are highlighled below. A social marketing campaign for condoms, managed by PSI with AIDSCAP funding since September 1992, resulted in the sale of 14 million condoms. The "baby friendly hospitals" initiative that UNICEF and PAHO jointly launched in 1994 to promote breast-feeding resulted in the certification of two hospitals as baby friendly in 1996. The national campaign for the eradication of measles, which was implemented in 19941995, achieved a 98% vaccination coverage. The national campaign for the promotion of breast-feeding that was launched in August 1995 reached the majority of the population. The observance of "Tuberculosis Day," "International Womens Day," "Safe Water, the Environment, and Health Day," "World No-Tobacco Day," "Mental Health Day," and "AIDS Day" receives media coverage.
School Health. The Ministries of Public Health and of Education, with external financial and technical assistance, are working together to develop school health policies appropriate for Haiti, including early detection of hearing and vision problems; promotion of oral health and detection of dental caries; nutritional surveillance; detection of iron deficiency and diseases caused by intestinal parasites; early detection of poor posture; health education and promotion, including sex education; and the prevention of STDs.
Workers Health. Haiti has no national health program for workers, but workers who receive coverage from the Agency for Occupational Accidents, Illness, and Maternity were given annual examinations to detect tuberculosis and syphilis. The Agency has a 30-bed hospital in Port-au-Prince that granted appointments to an average of 30 outpatients a day.
Programs for Disease Prevention and Control. In 1992, NGOs throughout the country allocated funds for the planning and implementation of vaccination programs in which regular staff members from public health facilities participated.
A vaccination campaign against measles was carried out between November 1994 and June 1995, resulting in the vaccination of 2.8 million children, which represents 98% of the target population of children between 9 months and 14 years of age. A countrywide network of four to five storage and distribution units for vaccines and supplies for immunization in each department was established. This process will be completed with the establishment of an active distribution system with motorized couriers.
In 1996, 200 clinics provided diagnosis, treatment, and follow-up of tuberculosis patients. The cure rate varied considerably from one department to another, ranging from 40 % to 78%. Improvements in cure rates are most likely the result of the increasingly widespread use of the short-course therapy. Training activities conducted from 1993 to 1995 targeted 828 health care workers. In 1995, the emergence of several cases of drug-resistant tuberculosis made it necessary to use costly second-line drugs. This significantly raised the cost of treatment for a drug resistant patient from US$ 45 to US$ 3,000.
Regarding malaria, the country pursues a primary health care strategy that involves the elimination of deaths and the reduction of morbidity rates by emphasizing early detection and timely treatment. The vector control component includes provisions for community participation. The Ministry of Health undertook the task of training all health care personnel in the prevention and control of malaria. Upon completion in 1997, a total of 3,500 health workers will have been trained.
Since 1991, AIDS control efforts have been supported technically and financially by four organizations, including: PAHO, USAID, WHO (GPA) and the French Cooperation, and UNFPA. This support has bolstered activities implemented by roughly 20 NGOs in the areas of serosentinel surveillance for HIV infection, IEC campaigns, production of IEC materials, training of health workers and community leaders to care for AIDS and STD patients, clinical and psychological care of patients suffering from STDs/AIDS in a reference center in Port-au-Prince and in three hospitals based in both urban and rural areas, financial aid and nutritional assistance for AIDS patients and their families in Port-au-Prince, distribution of condoms, and supply of drugs and materials for the prevention and control of STDs.
The Ministry of Health, PAHO, the GHESKIO Centers, and AIDSCAP NGOs have been developing simplified algorithms for the treatment of STDs. On January 1, 1996, UNAIDS officially began to operate in Haiti. The national program for the control of AIDS and other STDs was launched by the Ministry on World AIDS Day, December 1, 1996.
The Ministry of Agricultures Health Protection Unit is responsible for administering the strategy for the control of zoonoses. The Units Animal Health Service of has five veterinarians and 90 workers deployed throughout the country. Health officers are actively involved in efforts to control stray dogs and are working with Ministry of Agriculture personnel to conduct vaccination campaigns.
Regarding rabies control efforts, a national vaccination campaign for dogs and cats was implemented by the Ministry of Agriculture in 1995 with assistance from the United States Army, the Ministry of Health, and PAHO; the country is estimated to have approximately 100,000 dogs. More than 54,072 doses of vaccine were administered between July and August 1995, mostly in the metropolitan area.
Efforts to control micronutrient deficiencies mainly entail short-term supplementation interventions, including universal distribution of high-dose vitamin A prophylaxis of 100,000 UI to children 612 months of age and 200,000 UI to children 1272 months old at vaccination sites, universal distribution of vitamin A supplements (200,000 UI) to mothers within one month after delivery by community health workers or traditional birth attendants, iron-folate supplementation for those diagnosed with anemia, and targeted iodine capsule distribution in specific areas.
Foodborne diseases remain a public health challenge, due in part to the limited personnel involved in the inspection process and deeply-rooted cultural factors. The Ministrys Directorate of Health Environment and Epidemiology is responsible for control activities related to food safety.
Epidemiological Surveillance Systems and Public Health Laboratories. Until 1991, only four diseasespoliomyelitis, neonatal tetanus, AIDS, and cholerahad specific surveillance systems in place. Between late 1992 and 1995, several NGOs supported the establishment of a simplified epidemiological surveillance system that relies on monitoring simple operational indicators for principal diseases gathered through a network of private or semi-public sentinel facilities. In September 1996, the Ministry of Health created a committee to design and support the implementation of a new National Health Information System. The committees 16 members include representatives from the Ministries of Public Health, of Finance and Planning, and of External Cooperation; one NGO, and three technical cooperation agencies.
Drinking Water Services and Sewerage. The political crisis and ensuing trade embargo have greatly impaired the water supply and sanitation sector. Ongoing investment projects in this sector, totaling US$ 163 million, were interrupted. With no maintenance, the water supply infrastructure deteriorated rapidly, and service coverage levels in the capital fell by nearly 30% between December 1990 and December 1994. The crisis also disbanded the National Water and Sanitation coordinating committee and national water agencies. In October 1994, almost all projects that had been suspended in November 1991 were resumed, and since then, increasing amounts are being invested in the water supply and sanitation sector.
Municipal Solid Waste Management Services. Nearly 30% of the daily volume of solid wastes produced in Port-au-Prince is collected by the Ministry of Public Works and the municipality; an autonomous government agency in charge of solid waste management shut down in 1993. Service was more reliable in smaller cities, where collection was ensured by local services run by the Ministries of Public Works and of Health. Disposal of hospital waste also is poor.
Food Assistance Programs. Food aid is very important for Haiti, where growing numbers of households face escalating food security problems. Main donors were USAID, the European Union, and the World Food Program of the United Nations. Many NGOs and bilateral agencies also were involved in relief food distribution.
Organization and Operation of Personal Health Care Services
Ambulatory Services, Hospitals, and Emergency Services. Ambulatory care is delivered through outpatient facilities, clinics, and outpatient services in most hospitals; services vary greatly from one structure to another.
In 1993, a pilot project for emergency care was launched with the assistance of PAHO and physicians attached to the French Emergency Ambulance Service (SAMU). The project will lay the foundation for a countrywide emergency services network that would provide services ranging from screening and first aid (level 1) to specialized treatment (level 4). Four health centers in the metropolitan area are equipped with emergency units. In addition, the Haitian Red Cross and several new hospitals are establishing their own ambulance service and emergency telephone and radio communications. Training in emergency medical care was organized for health personnel throughout the country: 314 physicians, nurses, and health auxiliaries and 72 paramedics working in the public and private health sectors received the training. The experience is expected to serve as the basis for the formulation of a national plan for emergency care. The Ministry of Health includes emergency medicine/surgery in the minimum package of health services.
Auxiliary Services for Diagnosis and Blood Banks. The only medical testing laboratories are located in a few private or semi-public hospitals in the main cities, and they generally only conduct basic laboratory tests. A total of 122 public and private nonprofit institutions have diagnostic facilities for malaria, and 200 diagnostic centers are part of the tuberculosis control network, equipped to perform sputum examinations. There were no organized quality control services.
Since 1986, when the blood transfusion service operated by the Haitian Red Cross took over all the countrys blood transfusion services in hospitals located in major cities, blood has been screened for HIV infection. At the blood transfusion center in Port-au-Prince, blood donations also are systematically tested for hepatitis B (surface antigen) and syphilis (serologic testing for acquired syphilis). Because Haiti is considered to be highly endemic for HIV infection and syphilis and mesoendemic for malaria and hepatitis B, blood transfusions were kept to a strict minimum.
Specialized Services. According to the new health care policy, dental health is part of the package of health services. The current status of oral and dental health care in Haiti is marked by shortages of manpower and equipment. Some NGOs attempt to bring affordable, community-based solutions to oral and dental health problems.
There were no nationwide programs for the treatment of diabetes and hypertension. An NGO in Port-au-Prince provided prevention activities, medical care, access to drugs at a reasonable price, and rehabilitation services. Early detection of diabetes was impeded by several factors: the shortage of diagnostic tools and equipment, which were virtually nonexistent in rural areas; insufficient health facilities; low awareness among the general population; and the lack of an early detection policy.
Inputs for Health
Physical Infrastructure. The health care infrastructure and medical equipment are seriously impaired by a lack of maintenance and timely repairs. The deterioration in the condition of installations and equipment in public health care facilities was compounded by the nations three-year-long crisis. Between October 1994 and March 1996, a total of US$ 1,310,525 was spent on rehabilitation projects in 46 health care facilities and 5 hospitals, including the Haitian State University Hospital. A total of US$ 8,278,610 was invested for the partial rehabilitation of 88 health care facilities and 5 hospitals, including the University Hospital.
Access to Health Care. A total of 663 health facilities are located throughout the country. According to EMMUS-II most women in urban areas live close to health care facilities (79%98% in Port-au-Prince and 62%87 % in other cities). The situation in rural areas is quite different. In 1991, an estimated 40% of population had no access to primary health care services. Disparities are also evident in the deployment of health professionals throughout the country. Approximately 73% of all physicians, 67% of all nurses, 35% of all health care facilities, and 52% of all hospital beds are concentrated in the West Department and serve one-third of the total population. The distribution of population, health care personnel, and beds per 100,000 population by department, revealing the disparities in access to health care in Haiti.
Essential Drugs, Immunobiologicals, and Reagents. There were 4 drug manufacturers, 50 importers and suppliers, and 200 authorized private pharmacies in the Port-au-Prince area.
In 1992, with help from national and international partners, PAHO created an essential drug program (PROMESS) to distribute essential drugs and medical equipment in Haiti as part of humanitarian assistance; the Ministry of Health has chaired the board of PROMESS since 1996. The Ministry has approved approximately 400 essential drugs. Drugs for PROMESS were financed by internal cost recovery funds and by subsidies from international donors.
In order to promote the use of essential drugs, the Ministry developed training in essential drugs management for field-level personnel. Government peripheral warehouses, supplied by PROMESS, facilitated the distribution of drugs and medical supplies to health institutions in the countryside. Medicinal herb manuals in Creole are disseminated by a few NGOs.
UNICEF imported EPI vaccines and provided them free of charge; vaccines were stored at and distributed from the PAHO warehouse. Only a few reagents, such as stains for TB control, were prepared locally.
Health Technology. Health technology was extremely limited in Haiti. Radiology and radiation therapy services were concentrated in Port-au-Prince and in a few provincial hospitals, and most of the equipment was outdated. Well-trained technicians were rare, and dosimetry services and protective measures in and around X-ray rooms were unreliable. In general, modern diagnostic imaging equipment was located in the private sector. A Port-au-Prince private facility received its first CT scanner in 1995. Kidney dialysis services in Haiti were limited to two units in a private hospital.
Communications. A radio communications network known as the "a radio health network" was established in 1993 by PAHO/WHO in conjunction with health sector NGOs. It has proven invaluable, both for routine regulatory activities (logistics, administration) and for emergencies. The radio network has 15 affiliates. Five VHF relay stations provide coverage for approximately 70% of the country.
Availability by Type of Resource. The Ministry of Health is one of the countrys largest employers, with a staff of approximately 8,900 (19% of the civil service.) Of these, 38% are medical and paramedical personnel, with the other 62% representing administrative and support staff. There were large disparities in the nationwide deployment of MOH personnel. Department hospitals suffered from shortages of trained managers and personnel such as obstetricians/gynecologists, anesthetists, pediatricians, surgeons, orthopedists, midwives, and nurses. There are approximately 11,000 traditional birth attendants who attend nearly 80% of all childbirths.
The Faculty of Pharmacy trains an average of 25 pharmacists per year, but as the pharmaceutical arena does not offer attractive positions, many move abroad, or join the private sector as medical representatives or as chemists in the pharmaceutical industry.
Education of Health Personnel. In 1997, there were seven public institutions, including one school of medicine and pharmacy; one school of odontology; four nursing schools, one each, in Port-au-Prince, Les Cayes, Cap-Haïtien, and Jérémie; and one medical technology institute. A nongovernmental, nonprofit training institute on community health and epidemiology operates in Port-au-Prince. Around 80 medical doctors receive diplomas each year as well as 150 nurses.
Prior to 1993, many medical and paramedical training facilities were opened by private profit-making enterprises. There are 2 medical schools, 10 nursing schools, more than 40 training facilities for nursing auxiliaries, and several medical technology institutes. The degrees conferred by these establishments are not always recognized by the Ministry of Health. A four-year training project for traditional birth attendants (19961999), financed by UNDP, resumed in cooperation with the Ministry of Health.
Expenditures and Sectoral Financing
The budget of the State University Hospital in Port-au-Prince, although decreasing over the last three years, absorbed a significant amount of the public expenditure (17%); another 28% was spent on other public hospitals. Public expenditure on drugs accounted 3% of the total amount spent in 19951996, but most private and public institutions used a cost-recovery mechanisms. Public expenditure on equipment represented 4%5% of the budget; in addition, US$ 510,345 was spent on equipment in 19941995 through external aid for that purpose.
The Ministry of Health budget was 157 million gourdes in 1990 and 418 million in 1996, but due to inflation this represents a decrease of 27%. In constant 1990 values, the amounts are 157 and 115 million gourdes, respectively.
Government spending in health ranged between 7.1% and 10.7 % of the national budget between 1990 and 1996, representing approximately 1% of the GDP. Per capita public spending in health decreased from 25 gourdes in 1990 to 16 gourdes in 1996, in constant 1990 values. The figure for 1996, however, indicated an upward trend after four years of decrease during the political crisis. Until the mid-1990s, around 90% of public expenses had gone into wage and salary payments, exhausting the working capital for health care facilities, whose services steadily deteriorated. Under the 1995 and 1996 budget, the share of wages and salaries was expected to be limited to 70%, but this was not fully implemented and their share remained at 80% in 1996.
The Ministry of Social Affairs, through its social Welfare Institute, addressed such issues as sexually transmitted diseases in prostitutes, provided prenatal care, oversaw the welfare of street children, and provided doctors for orphanages within its purview. The Ministry of Agriculture was actively involved in programs for the control of zoonoses, the water supply in rural areas, and the food/work program. The Ministry of Education planned school health programs and has been in charge of the schools of medicine, pharmacy, and odontology since 1995. The Ministry of Womens Affairs and Womens Rights issued a policy paper on womens health in 1995, evaluated womens prison conditions, and developed a standard medical record for use in the prison health services. A memorandum of understanding for the improvement of prison conditions was drafted and submitted for approval by four cabinet ministries (Social Affairs, Health, Justice, and Education). The Ministry also published a guide for the evaluation of womens shelters and took part in an effort to educate groups of women from grass-roots organizations on reproductive health and AIDS. The Ministry of the Environment campaigned to heighten public awareness on the importance of protecting nature and identified strategies for the control of deforestation. The Ministry of Public Works played a major role in water supply and sanitation programs and in efforts to upgrade the nations roads. The Metropolitan Water Company, the National Water Supply Service, and the Metropolitan Solid Waste Collection Service are all attached to the Ministry of Public Works.
Charging and collecting fees in both the private and the public sector is sometimes used to provide care to clients without resources. However, the amounts cannot cover the entire cost of the services.
External Technical and Financial Cooperation
A large share of expenditure in health came from foreign aid, particularly for capital outlays and operating expenses. International aid represented more than 50% of total public spending, reaching 78% in 19941995. Before 19961997, the main donors were USAID, France, Canada, and Japan; the European Union has now become the major donor in the sector.
Most NGOs operate independently. The 100 affiliates of the association of private health institutions are scattered throughout Haitis nine departments. This NGO provided technical assistance and served as the coordinator and spokesperson for affiliated NGOs. NGOs and the private sector have generally operated independently of the Ministry of Health.
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