Pan American Health Organization

Haiti

  • Overall Context
  • Leading Health Challenges
  • Health Situation and Trends
  • Prospects
  • References
  • Full Article
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Overall Context

Flag of HaitiHaiti occupies the western third of the island of Hispaniola in the Greater Antilles chain in the Caribbean; the Dominican Republic occupies the eastern part of the island. The country has a landmass of some 27,750 km2, with mountains covering 80% of the territory. Haiti is divided into 10 departments, 42 arrondissements (similar to districts), 140 communes (similar to parishes), and 570 communal sections. The two official languages are French and Creole but the latter is the most commonly spoken.

Demographics

Haiti’s 2015 population was estimated by the Haitian Institute of Statistics and Informatics to be 10,911,819 (); more than 25% of the population lives in the metropolitan area of Port-au-Prince, the country’s capital. With an annual growth of 1.67%, the country’s population is expected to reach 11.7 million by 2020 (). For the period 2015-2020, life expectancy at birth is estimated to be 64.2 years (compared to 60.6 for the period 2005-2010); the crude birth rate is estimated to be 24.1 births per 1,000 population; and the crude death rate 8.2 deaths per 1,000 population (). The total fertility rate declined from 4 children per woman in 2006 to 3.5 in 2012 (). Haiti’s population is young, with more than 50% under the age of 23, 34% under the age of 15, and 4.5% over the age of 65 (). Figure 1 shows the change in population structure between 1990 and 2015; less growth in the population under age 30 reflects decreased fertility. The dependency ratio fell by nearly 11 points (from 73% to 62%) between 2007 and 2012 (). Countrywide, the male-to-female ratio is 95:100; in Port-au-Prince that ratio is 84:100. The urbanization rate increased from 47.8% in 2010 to 51.9% in 2015 (). According to the 2012 Mortality, Morbidity, and Service Utilization Survey (EMMUS-V) (), 20% of children under 5 years old had not been entered in a civil registry.

Figure 1. Population structure, by age and sex, Haiti, 1990 and 2015

The Haitian population increased by 50.9% between 1990 and 2015. In 1990, the population structure showed fast expansion, while in 2015, the pyramidal structure reflects slower expansion in the population under 30 years of age, related to a decrease in fertility and mortality since 1990. It remains a relatively young population, with more than half under 25 years of age.

Source: Pan American Health Organization, based on data from the United Nations Department of Economic and Social Affairs. Division of Population, New York, 2015. Updated 2015.

The Economy

According to the World Bank, GDP per capita was estimated at US$ 820 in 2014. Despite favorable conditions (reconstruction after the earthquake in 2010 and foreign assistance), the GDP growth rate has declined from 5.5% in 2011 to 1.7% in 2015. With a population that grows on average by 2% per year, any growth below 2% of GDP is insufficient to offset the demographic pressure. Moreover, inequalities, already extremely significant, continue to widen. The Gini coefficient measuring income inequality rose from 0.61 in 2010 to 0.66 in 2012 (). Haitian currency depreciated by an average of 2% to 3% annually between 2005 and 2014, but between 2014 and 2015 depreciation reached 14.5%. Inflation accelerated to 14.4% in early 2016, driven mainly by rising prices of locally produced food due to drought. It can be expected that the poverty, which already affects two-thirds of the population, will increase.

The Haitian government lacks resources and has not been able to implement needed social programs or develop a sustainable economy that is resilient in the face of crises, such as natural disasters and civil unrest. Haiti imports three times more than it exports and its most important resources are remittances from the Haitian diaspora (an estimated US$ 2.1 billion in 2015). Between 2014 and 2015, contributions from the PetroCaribe program decreased by half as a result of low oil prices. Foreign assistance decreased by 75% between 2010 (US$ 1.8 billion) and 2015 (US$ 488 million). In 2015, drought had a significant impact on the agricultural sector, which accounts for one-fifth of GDP. The prerequisites for the local and foreign investment needed to boost and sustain economic growth have not been met in the areas of policy, governance, and justice.

Leading Environmental Problems

The country is located in an area that is prone to earthquakes and severe tropical storms. This vulnerability is increased by significant soil erosion resulting from deforestation. In addition to physical and environmental vulnerability, Haiti has experienced recurrent political instability. The 2015 presidential and parliamentary elections were stopped after the first round; the electoral process was rescheduled for October 2016 but was postponed again due to Hurricane Matthew. The United Nations Stabilization Mission in Haiti (MINUSTAH) has operated in the country since 2004.

For the last 30 years Haiti’s natural resources have been under increasing pressure. Population growth, poverty, and a high level of consumption of firewood and charcoal for cooking have contributed to extensive deforestation. The country had enjoyed a surplus of water resources but no longer has enough to satisfy the needs of a growing population. The lack of water catchment and storage systems contributes to the under-supply of safe drinking water, particularly for the poorest strata of society. The phenomena of unplanned urbanization and invasion of protected watersheds increase contamination of water used for human consumption.

The effects of climate change and global warming make Haiti vulnerable to hurricanes as well as regional climate phenomena such as “El Niño.” The country’s agricultural production has suffered due to “El Niño” effects; a significant reduction in rainfall and changing seasonal patterns in 2014 and 2015 resulted in the loss of many crops (). The global report on risk reduction related to disasters, published by the United Nations Office for Disaster Risk Reduction (UNISDR) in 2015 (), stresses that the impact of disasters on Haiti’s development capacity is one of the highest in the world.

Health Policies, Plans, and Programs

In 2012, the Haitian government elaborated the National Health Policy (), a 25-year plan to reduce morbidity and mortality linked to major health problems and to build an efficient, accessible, and universal health system. The specific objectives are to: i) establish a health system able to ensure universal health coverage and meet the basic needs of the population while promoting the articulation of modern and traditional medicine; ii) ensure the leadership of the Ministry of Health in monitoring and securing the population’s health status and regulating and accrediting health institutions; iii) ensure adequate funding of the health system by gradually increasing the percentage of the public treasury allocated to health; iv) use performance-based results and accountability to align the activities of partners with national priorities; v) establish an emergency response system throughout the health sector that is capable of responding to natural disasters and other emergencies; and vi) ensure that goals and objectives arising out of national and international commitments are met.

The Health Master Plan for 2012-2022 articulates how the National Health Policy will be put into action. It addresses organizational strengthening in the areas of governance, the health information system, management of health care services, and resources. It identifies the main objectives in the provision of women’s health and maternal and child health services and health care for adolescents and young adults. The plan emphasizes approaches in combating communicable and noncommunicable diseases (NCDs), prevention of violence and accidents, and issues of nutrition, health promotion, risk and disaster management, sanitation, and environmental health.

In December 2015, the Ministry of Health, the National Directorate of Water Supply and Sanitation, and the Ministry of Trade and Industry defined a new framework for monitoring the quality of water for human consumption. The agreement, “Promotion of Sanitation, Hygiene, and Life,” was signed in February 2016, and revision of sectoral legislation began in order to adapt it to the needs of Haitian society of the XXI century.

In June 2015, the Ministry of Health signed an agreement with the Ministry of Public Works to implement the national road safety strategy for 2015-2020, which, among other things, aims to improve the treatment of victims of road accidents.

Social Determinants of Health

Although extreme poverty in Haiti dropped from 31% to 24% between 2002 and 2012 (), 2.5 million people (one-quarter of the population) are unable to cover their basic food requirements. It is estimated that 6 million people are living under the poverty line of US$ 2 per day (). Haiti is still one of the world’s most unequal countries in terms of income distribution, and the gap has grown in particular between Port-au-Prince and rural areas. Employment is not enough to lift people out of poverty because 45% of workers earn less than US$ 1.25 a day ().

Haiti has made limited progress in providing its population access to basic services, but coverage remains among the lowest of any country in the Americas. Only 36% of the population had access to electricity in 2012 (compared to 32% in 2010); 57.5% had access to clean water in 2015 (36% in 2000); and 28% had access to basic sanitation in 2015 (21% in 2000) ().

Literacy rates in Haiti have seen substantial gains, from 64% in 2003 to 79% in 2012 for males and from 54% to 74% over the same period for females (). However, 23% of the general population is illiterate, a figure that rises to over 30% in rural areas (). The net enrollment rate in primary school has continuously increased from 47% in 1993 to 88% in 2011 (). The primary completion rate declined to 66% in 2012 from 68% in 2001, and less than 10% of the population completes secondary or higher education. The majority of schools are non-state, and 67% of students attend private schools (fee-paying) ().

Vulnerable Populations

One-quarter of Haitian children aged 5 to 17 years live separated from their parents. Most of them (21%) live with another family member and 4% live with a third party. Those living with a third party are less likely to attend school and perform more domestic labor than children living with their parents or another family member. An estimated 286,000 of children between 5 and 14 years old in Haiti are classified as child domestic workers, based on their relative workload, access to education, and separation from their parents (). Typically, these children are placed with third parties with the expectation of improved opportunities, but are vulnerable to exploitation.

The Health System

The leadership of the health system is provided by the Ministry of Health, which has central offices in the capital and directorates in each of the country’s 10 departments. The work of the Ministry is framed by the development and implementation of the Health Master Plan, a comprehensive strategy.
The formal health service network is organized in 10 health departments. In 2012, the Ministry of Health proposed a new subdivision, district health units (Unités d’Arrondissement de Santé) based in the country’s 42 districts. These units have the mandate to coordinate the health network at the primary care level. Their capacity to do the job is uneven from department to department, due mainly to the lack of human resources.

The health care delivery system is structured into three levels: primary care is provided at some 800 health centers and 45 community reference hospitals; 10 departmental hospitals provide secondary care; and five university hospitals and three specialized centers provide tertiary care. Of over 900 health institutions, 38% are public, 42% are private, and 20% are mixed (). Both for-profit and nonprofit private facilities have a significant presence in Haiti, especially in metropolitan areas, but are poorly coordinated with the public sector. Almost half of health facilities are located in the metropolitan area of Port-au-Prince, where 35% of the population resides. Traditional medicine plays a major role for the population seeking health care.

Leading Health Challenges

Critical Health Problems

Emerging Diseases

The cholera epidemic started in Haiti in the last quarter of 2010. The attack rate was 1.84% in 2010, peaked at 3.44% in 2011, and fell to 0.39% in 2015 thanks to a strong response system. The disease is now endemic in the country. The annual number of cholera cases was 29,078 in 2014 and 36,045 in 2015. In 2016, 23,933 cases had been reported by July 30, more than for the same period in 2015.

In 2013, the Haitian government launched a 10-year national plan for the elimination of cholera. Response capacity was strengthened by the work of 10 mobile rapid response teams created in April 2014 and the establishment of a disaster response coordination unit within the Ministry of Health. In addition to strengthening health promotion activities, in 2013, the Ministry launched vaccination campaigns with the goal of reaching nearly 600,000 people by the end of 2016. In April 2016, experts recommended widespread use of cholera vaccination in at least 1 of the 10 departments of the country (the Centre department), after lessons learned from small-scale vaccination campaigns in 2013 and 2014, coupled with access to chlorinated water in all homes in Haiti. After Hurricane Matthew, the campaign also covered South and Grand’Anse departments, which were the most affected by the hurricane.

From 2012 to August 2016, 663 suspected cases of dengue were reported through the national epidemiological surveillance network. Of the 308 blood samples tested, there were 74 positive cases (positivity rate 24%). The outbreak of chikungunya fever appeared in Haiti in April 2014 and the epidemic peak occurred in June 2014, with over 12,000 cases reported weekly (). In all, nearly 70,000 suspected cases were reported in 2014, and of 25 tested cases 20 were positive. In 2015, 264 suspected cases were reported, and in 2016, 238 suspected cases were reported; no positive case was identified in either year. Vector control associated with individual prevention against mosquito bites is the key action for prevention of dengue and chikungunya.

The Haitian Ministry of Health reported 3,036 suspected cases of Zika fever between mid-October 2015 and early September 2016 (see Figure 2). Of the 259 cases tested, 19 were positive. Twenty-two suspected cases were reported in pregnant women by the surveillance network (). Ten cases of Guillain-Barré syndrome were suspected to be linked with the Zika virus (nine in the Centre Department and one in the West Department), but due to the lack of laboratory capacity, only one case was biologically confirmed. As of March 2016, 18 cases of congenital microcephaly had been investigated, and only 1 case was confirmed linked with Zika virus (using reverse transcription polymerase chain reaction-RT-PCR).

Figure 2. Epidemiological profile of suspected cases of Zika, Haiti, 2015-2016


Note: Suspected Zika cases reported from epidemiological week 42 of 2015 to the 35th epidemiological week 35 of 2016.
Source: Haiti, Ministry of Health, Directorate of Epidemiology, Laboratory, and Research.

The Ministry of Health, supported by its partners, developed a response plan to Zika that focuses on epidemiological surveillance, communication and social mobilization, strengthened family planning, vector control, care of sick people, and monitoring and coordination of interventions. The partners supported the country in supervising the plan, vector control, and laboratory diagnosis at the national level. Currently the national laboratory of Haiti has the capacity to do the laboratory diagnosis.

Neglected Diseases and Other Infections Related to Poverty

Lymphatic filariasis is endemic in Haiti (). Since 2012, Haiti has successfully implemented treatment against lymphatic filariasis at a national scale. In 2013, over 7.8 million people received drugs against filariasis (80% of the target population), followed by 5.5 million in 2014 and 5 million in 2015. All municipalities in the country received at least one mass treatment campaign using diethylcarbamazine citrate (DEC) and albendazole. The dose is repeated yearly for 5 years. The goal of the national program is the elimination of filariasis by 2020, which requires continuity of partner support.

The prevalence of intestinal helminths in schoolchildren was estimated at 30% in 2013. The first deworming campaign using albendazole was organized in 2015 and reached 994,668 children between the ages of 2 and 14 years.

Tuberculosis

The number of tuberculosis cases in Haiti was 14,222 in 2010 to 16,431 in 2015. The incidence rate (including coinfection with HIV) declined from 230 per 100,000 in 2010 to 200 per 100,000 in 2013, and the prevalence rate decreased from 325 to 244 per 100,000 for the same period (). Despite this improvement, the rates are the highest in the Americas. The TB mortality rate was 25 per 100,000 in 2012. The treatment success rate is stable at 78% (the objective of the national program is 85%) and the treatment dropout rate was 10% in 2015 (compared to 7% and 8% in 2011 and 2012). According to the World Health Organization (WHO), only 20% of the estimated 400 multidrug-resistant TB cases were detected from 2012 to 2014, and preliminary results show the same trend in 2015. Haiti has long been a beneficiary of international aid to strengthen the national TB control program and now has an improved task force at the national and departmental levels, decentralized laboratories for diagnosis, and a regular supply of drugs.

HIV/AIDS

Haiti is heavily affected by HIV, with a prevalence of 2.2% in adults 15-49 years old (). Prevalence in 2012 was similar to that observed in 2006, showing a trend toward stabilization of the epidemic (). The female-to-male infection ratio of 1.59:1 highlights the greater vulnerability of women to HIV infection. According to the results of a behavioral and biological surveillance study conducted in 2012 by the nongovernmental organization Population Services International (PSI), the prevalence of HIV infection is estimated to be 8.4% among sex workers and 18.1% among men who have sex with men and transgender people.

The national response to HIV in Haiti has intensified in recent years and the incidence of HIV continues to decline. According to estimates revised in 2015 through the SPECTRUM tool of the Joint United Nations Programme on HIV/AIDS (UNAIDS), a total of 8,200 people were infected in 2014, compared to 11,300 in 2004, a decline of 27% in 10 years.

The number of people who die from AIDS-related causes has experienced a considerable decrease. Estimates made by the National Program to Combat STI/HIV/AIDS in 2015 show that the number of AIDS deaths in 2014 was 3,800 compared to 7,800 in 2008: a decrease of more than 50% over six years. The survival of virus carriers has been significantly improved. Through the use of care and treatment services, it is estimated that between 6,200 and 6,600 deaths are avoided per year. As part of the prevention of mother-to-child transmission (MTCT) of HIV, the number of pregnant women who received treatment during a single year more than doubled, from 2,500 to 5,226, between 2008 and 2013. Ninety percent of HIV-positive pregnant women identified in the system in 2015 received treatment.

Maternal Mortality

According to WHO estimates, the maternal mortality ratio fell from an estimated 630 deaths per 100,000 live births in 2005-2006 to 380 per 100,000 in 2013 (). Based on the number of maternal deaths reported by health institutions, the Ministry of Health estimated the maternal mortality ratio at 157 per 100,000 in 2013 (). Despite the differences in methodologies and estimates, there has been a marked decline in the maternal mortality ratio in Haiti, but it still remains the highest in the Western Hemisphere.

A high proportion of women (63%) do not receive qualified obstetrics assistance at the time of delivery (). In 2013, only 43% of health care facilities offered delivery services and 10% provided caesarean section (). According to the Ministry of Health, in 2015, 89% of institutional deliveries occurred in Comprehensive Emergency Obstetric and Neonatal Care units (CEmONC) units and only 11% in Basic Emergency Obstetric and Neonatal Care (BEmONC) units. In its 2013-2016 interim strategic plan for reproductive health, the Ministry stated its objective was to strengthen 88 BEmONC units around the country to reduce maternal mortality and to provide qualified staff (mainly midwives).

Adolescent Pregnancy

In the 2012 EMMUS-V survey () it is reported that 14% of young women age 15-19 have begun childbearing: 11% had at least one child and 3% were pregnant with their first child. The proportion of adolescents who have begun childbearing decreases substantially when the level of education increases, going from 27% among adolescents with no education to 9% among those with secondary education or higher. Adolescent pregnancy has declined significantly from the 18% reported in the EMMUS survey conducted in 2000 (), but remains virtually the same as estimated in the EMMUS survey for 2005-2006 (). The unmet needs for family planning are particularly high among young people (57%).

Chronic Conditions

The real dimension of chronic NCDs in Haiti is not well known due to the lack of systematic data collection and surveys on these diseases and their risk factors. In 2014, the incidence of diseases recorded by health facilities was: 184,570 cases of hypertension (110,394 in 2010), 36,796 cases of diabetes, and 6,498 cancer cases (all types) (). Cancers of the cervix and breast were the most prevalent in women and prostate cancer was the most prevalent in men. Figures 3 and 4 show WHO estimates of the incidence of major cancers in Haiti in 2014 based on national mortality estimates ().

Figure 3. Annual estimated number of cancer cases, by site, females, Haiti, 2014


Source: World Health organization, Country Cancer Profiles, 2014. Available from: http://www.who.int/cancer/country-profiles/hti_en.pdf?ua=1.

Figure 4. Annual estimated number of cancer cases, by site, males, Haiti, 2014


Source: World Health organization, Country Cancer Profiles, 2014. Available from: http://www.who.int/cancer/country-profiles/hti_en.pdf?ua=1.

Mental Health

For decades, the people of Haiti have experienced trauma related to political violence, socioeconomic hardship, a series of catastrophic natural disasters, and finally, the cholera epidemic. The prevalence of mental health problems is not really known. There are only two public, specialized mental health institutions, providing 180 beds (a ratio of 1.7 beds per 100,000 inhabitants). The staff dedicated to the care of people with mental illness is very small, a ratio of 0.028 psychiatrists, 0.014 general practitioners, 0.038 nurses, and 0.086 social workers per 10,000 population (). Very few psychologists are available.

Human Resources

Human resources for health remain a major challenge for Haiti; the country has no policy for human resources in health. Further, the country lacks reliable data on human resources, and the Ministry of Health is working with the Pan American Health Organization (PAHO) to organize an observatory to provide the data necessary to develop policies. The Repository of Jobs and Skills (Référentiel des Emplois et des Compétences (REC)) and a recruitment guide published in December 2011 by the Ministry of Health are important steps in the development of tools for human resources management. Areas that need improvement include the balance between numbers of administrative staff and staff providing care, strategies for career advancement and improved health worker status, and the development of a clear policy of remuneration for health workers.

According to the assessment of human resources in health care institutions conducted by the Ministry of Health in 2016, there are 15,980 health professionals in the public sector and 7,364 in the private sector (a total of 23,344). Nationwide, the proportion per 10,000 inhabitants is 1.4 physicians and 1.8 nurses in the public sector, and 1 physician and 2.1 nurses in the private sector. The ratio of physicians and nurses is unequal through the departments of the country. In the public sector, West Department has 2.1 physicians per 10,000 inhabitants; North, 1.8; Northeast, 1.3; South, 1.3; and Northwest, 0.7. The other departments have less than 1 public sector physician per 10,000 inhabitants. The same trend exists for public and private physicians combined: West, North, Northeast, and South Departments have, respectively 3.7, 2.6, 2.4, and 2.3 physicians per 10,000 inhabitants. Northwest Department has 1 physician and Artibonite and Grand’Anse each have 1.2 physicians per 10,000 inhabitants.

Health Knowledge, Technology, and Information

The Haitian health care system has suffered from the lack of a comprehensive information system capable of tracking and mapping access to health services and health outcomes and obtaining information on disease outbreaks. With the development of the National Health Information System (Système d’Information Sanitaire National Unique (SISNU)) the Ministry of Health is working to harmonize data production, maintain reliable and comprehensive information about the health status of population, and meet partners’ needs for information. Emphasis is being given to strengthening epidemiological surveillance and health service statistics. The implementation of the National Health Information System is a participative process with the Ministry and national and foreign partners.

The interventions carried out through this initiative have had tangible results, characterized among other things by strengthened leadership of the Ministry of Health on national health information and the development of the list of essential health indicators. Tools for collecting and reporting data have been standardized in the majority of health facilities in the country. The District Health Information Software (DHIS2), a web-based platform used to capture, process, analyze, and present data, has been launched in the health directorates of all departments and in some service delivery sites. Improvements have been made in the completeness and timeliness of data and in access to health information. To preserve these gains, the Ministry will continue to emphasize the improvement of data quality and the use of information for programmatic decision-making at all levels of the health system.

The Environment and Human Security

Access to Clean Water and Sanitation

According to the EMMUS-V survey in 2012 (), the percentage of the population with access to safe drinking water improved slightly between 2005 and 2012 (from 61.6% to 64.8%), but access is still insufficient for the needs of the growing population. Only 9.2% of households have water supplied through a home connection. There is also a significant difference in access to safe drinking water between urban (88%) and rural (49%) areas. The vast majority of drinking water systems operate in a rationing regime that is insufficient for demand and makes it difficult to control the quality of the water.

Only 25.7% of the population used improved toilets. The proportion that practiced open defecation or used unimproved facilities was 44.2% of the population in 2012 (17.6% in urban areas compared to 62.8% in rural areas). The practice of hand-washing, well known by the population as a result of campaigns to promote hygiene since the cholera epidemic in 2010, is limited by the difficulty of obtaining water and soap.

Solid-waste Disposal

Municipal waste collection services exist only in the main cities of the country and work irregularly. Garbage is dumped in the streets, fills drainage canals, and is frequently burned. The sorting of waste in landfills of the main cities is carried out in conditions that are dangerous to workers.

Most of the health care institutions have difficulties managing hazardous medical waste, with nonoperational waste management systems; personnel working under hazardous conditions; insufficient protection sites; and dysfunctional sorting, storage, and incineration equipment.

Air and Chemical Pollution

Air pollution is a serious risk factor for the Haitian population. The use of solid fuels such as charcoal for cooking and heating, the practice of burning trash in urban neighborhoods in the absence of solid waste management, and deficient regulation of vehicle emissions have a negative effect on public health in Haiti. The lack of solid and hazardous waste management allows used oil, existing heavy metals in electrical appliances, and batteries to pollute waterways and subsoil.

Deforestation and Soil Degradation

Deforestation and loss of vegetation cover in areas of food crops are one of the main threats to the environment in Haiti (). The proportion of natural forests was estimated at 2.6% of the territory in 2010, compared to 5.5% in 1956. Since 1990, forest plantations increased by 133%, from 12,000 to 28,000 hectares, representing 1% of the total land area. The main cause of deforestation is the population’s dependence on wood and charcoal for energy and is a significant contributor to soil erosion. Associated with high population density and sprawl of housing in hazardous, unstable areas, soil erosion increases the vulnerability of the population to natural disasters, particularly severe weather events and landslides.

Violence

Domestic violence is common in Haiti. In the 2012 EMMUS survey, over one-quarter of women aged 15-49 (28%) reported that they had experienced physical violence since the age of 15 and 13% of women aged 15-49 stated that they had been sexually abused at some point in their lives (). According to the report of the National Human Rights Defense Network (), during the period from May 2013 to May 2014, 581 murders, 24 kidnappings, and 148 rapes took place. The homicide rate was estimated at 10.2 per 100,000 inhabitants in 2012 (compared to 5.1 in 2007), which is below other countries in the region.

Natural Disasters

The earthquake that struck Haiti on January 12, 2010, is among the four deadliest recorded in the world since 1990 (); it led to the death of over 200,000 people and caused many more injuries. The earthquake hit the metropolitan area of Port-au-Prince where over one in five Haitians lived, destroying infrastructure, public buildings, and housing. The earthquake aggravated the already deteriorating infrastructure and poor living standards in the country. Despite the immediate intervention of the international community through the dispatch of rescue teams, and the infusion of financial and material support in the process of reconstruction and development, the situation has yet to normalize. In 2016 there are still tens of thousands of displaced people living in camps around the city. Hurricane Sandy in 2012 severely affected more than 200,000 people and caused an estimated US$ 104 million in agricultural losses. In October 2016, Hurricane Matthew, the most severe hurricane to hit Haiti since Hurricane Cleo in 1964, caused devastation in the southwest of the country, particularly in Grand’Anse Department. Hundreds of people were killed, and nationwide an estimated 200,000 homes were destroyed and 1.4 million people affected. Agricultural losses were total in the Grand’Anse and South departments.

Food Security

Following the earthquake of January 12, 2010, the food security score remained relatively stable between 2011 and 2013, with an average prevalence of food insecurity of 30%. The poorest households spend nearly three-quarters of their total income on food, and even among the wealthiest households, more than half of household expenditure is on food. This trend is observed both in rural areas (68%) and in urban areas (58%) ().

The drought that affected Haiti in 2014 and 2015, aggravated by the “El Niño” phenomenon, has had an impact on food security by declines in agricultural production. According to Haiti’s National Council on Food Security (CSNA), in the beginning of 2016, 3.6 million Haitians were food insecure, including 1.5 million severely food insecure and 200,000 (40,000 families) in extreme food emergency (). In response to this alarming situation, the Ministry of Agriculture drew up an emergency response plan to address the urgent needs of 40,000 families in 20 communes living in situations of acute food insecurity and to ensure, with the Ministry of Health, the nutritional management of target groups in the affected areas.

Migration

The Haitian Government formulated a Migration Policy Document in August 2015 to provide an inventory of Haitian migration (). Internal migration from rural to urban areas is continuous, and in 2015 the urbanization rate was over 50% of the population. In 2003, one-third of the population reported having at least one parent living abroad, and in 2015, the number of Haitian emigrants was calculated to be 751,245. It is estimated that in 2015 remittances from Haitians living abroad accounted for 35% of the country’s GDP. There is constant movement of agricultural and manufacturing workers to neighboring countries, mainly to the Dominican Republic, and in recent years, South America has become a new destination for Haitian migrants (particularly Brazil, Ecuador, and Chile).

Monitoring activities of individuals returning from the Dominican Republic were organized by the International Organization for Migration (IOM) and civil society partners after the June 15, 2015, deadline for the registration component provided by the National Regularization Plan for Foreigners established by the Dominican government. From June 2015 through June 2016, 109,783 individuals returned to Haiti; 68,031 reported that they returned spontaneously, 20,024 said they had been deported, and 21,559 people were deported officially. The Ministry of Health developed a contingency plan that provided for aid stations at reception points at the border that were linked to health centers and referral hospitals in border municipalities, health surveillance activities, epidemiological surveillance, and health promotion.

Monitoring the Health System’s Organization, Provision of Care, and Performance

Considering the large number of health actors working in Haiti, it is crucial for the national health authority (Ministry of Health) to provide leadership, coordination, management, and adequate control of the system. The Ministry has developed the Health Master Plan to guide the management of health services in all areas of the country.

The Haitian health system faces many challenges in terms of financial, human, and material resources, and the Ministry of Health continues its efforts to maximize the use of the financial resources available to the system to form a network of services to improve access and quality of health care for the population. Between 2011 and 2015, more than 270 projects to build and rehabilitate health infrastructure were completed.

In 2016 the Ministry revised the Essential Package of Health Services, which defines the service delivery model at the primary and secondary levels of Haiti’s health facilities.

Considerable progress has been made in the majority of health programs between 2011 and 2016 (), but much remains to be done. Institutional strengthening, extension of health services, and accessibility are among aspects of the health care system which are far from the objective of universal access and universal health coverage.

The National Ambulance Center (Centre Ambulancier National or CAN) has been an important addition to the health system in Haiti. It was established in 2012 as a partnership between the Ministry of Health and private, nonprofit entities. With 72 ambulances, 5 ambulance boats, and 1 ambulance helicopter, the service covers all of Haiti and has provided transport and emergency medical treatment to more than 70,000 patients.

As part of the governance and financing of health services, the sector favors results-based financing. Based on experiences with projects administered by nongovernmental organizations between 1999 and 2010, the strategy of results-based financing was incorporated as a national strategy by the Ministry of Health in 2013 and launched in August 2014. The results are not yet documented.

Total health expenditure as a percentage of GDP, which rose from 5.3% to 6.4% between 1995 and 2009, increased to 9.4% in 2013 (). According to the WHO Global Health Expenditure Database, total spending per capita on health was less than 100 international dollars (PPP) from 1995 to 2009, but increased significantly since 2010, reaching 229 international dollars in 2014. However, this increase in health spending is attributable to the significant and continuous increase in private expenditure on health while public health spending has continued to decline since the late 1990s. Since 2007, public health expenditure has represented less than 10% of total health expenditure and less than 5% of the national budget, despite the 15% target set in 2012 as part of the national health policy (see Figure 5).

Figure 5. Public expenditure in health, as a percentage of total pulic expenditure, Haiti, 1995-2014


Source: World Health Organization, Global Health Observatory Data Repository: health/system/financing health, 2016. Available from: http://apps.who.int/gho/data.

The share of social security expenditure in health public spending is very low, less than 5%, but there are some public health insurance programs that cover a very small percentage of the population (around 3.3%) (). It is estimated that in 2012, two-thirds of the population living in poverty did not access health care for financial reasons (). With the exception of severe crises, such as the aftermath of the 2010 earthquake, the share of direct spending in health by households is extremely high, reaching 34.8% in 2014 (). (See Box 1 on Haiti’s efforts to improve health care access after the 2010 earthquake.) This total lack of financial protection against health risks in normal times excludes a significant proportion of the population, mostly the poor, from health services. External funding has been significant in helping Haiti in times of crisis, but it is extremely unpredictable. While this funding may reduce household health spending during crisis, it is volatile and does not contribute to strengthening institutions.

Box 1. Haiti works to Improve Health Access after the 2010 Earthquake

In an effort to improve access to health care in the aftermath of the 2010 earthquake, the Ministry of Health developed a new model of community health care organization based on primary health care and an integrated health services network. The Ministry, with technical support from the Pan American Health Organization, launched a pilot project in the Carrefour community, a municipality near Port-au-Prince.

Primary care health facilities in Carrefour were organized into a network with a municipal health committee. Community health workers were recruited, trained to carry out multi-purpose functions, and inserted into the community with responsibilities for a well-defined area and population. A family health team, consisting of a doctor and two nurses, oversaw the planning, monitoring, and supervision of activities. The community health workers’ activities included identification and conducting an accurate census of the population under their responsibility, carrying out home visits and health promotion activities, and working once a week in the Carrefour network of health facilities.

Between 2011 and 2015, the Carrefour population experienced included a marked improvement in immunization coverage of children under 1 year old (from 37% to 89%) and an increase in family planning consultations (increase of 20% of annual new acceptants) and institutional deliveries (increase of 16% of annual institutional deliveries). The Ministry of Health will now extend this model to other municipalities in the country.

Prospects

The 2013 United Nations Development Programme (UNDP) report on progress toward the Millennium Development Goals (MDGs) (10) shows that there has been undeniable progress in Haiti’s health sector. The Sustainable Development Goals (SDGs) represent new challenges, and in reaching these objectives, it is important to take into account the lessons learned. It is essential to identify the most effective priority interventions in the health sector, to take into account the real capacities of the country in the financing and implementation of the identified strategies, and to ensure better coordination of interventions.

The main challenges are: vulnerability of the physical and human environment, dependence on international assistance, poor access to quality health services, weak health information and monitoring systems, prevention and control of NCDs, development of activities to strengthen maternal and child health care, and the limited resilience of the health sector to respond to health emergencies and natural disasters.

The Haitian government must redouble its efforts to increase the allocation of funds in the national budget to the health sector to ensure sustainability of programs and to deal with these challenges. Affordability of health care should be addressed and social protection strategies in health must be developed. The application of International Health Regulations (IHR) requires political will and support. Strengthened networks of multipurpose community health workers are essential to ensure universal access and health coverage for the population.

The continued engagement of health partners is important and could be made more effective by ensuring their alignment with priority needs defined by the government. The design and implementation of health financing strategies can facilitate greater predictability and durability in partnerships with the State, and support its commitment and accountability in strengthening the health sector.

References

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Reference/Note:

1. Annual reports on immunization performance from the Ministry of Health to WHO/UNICEF
(http://www.who.int/immunization/monitoring_surveillance/data/en/).

Regional Office for the Americas of the World Health Organization
525 Twenty-third Street, N.W., Washington, D.C. 20037, United States of America