Main Health Issues in Haiti: A Brief Review

Haiti reports a chronic structural and organizational crisis dating back more than 30 years. It is described 3 main tracks missing in the Haitian health system: geographic coverage, pointing to the problem of access to health care; financial coverage, and the inadequacy of basic health services. The problem of infrastructure, organization and training leads to disparities in the population where the most vulnerable are the ones who pay the consequences. This document presents a few statistical lines that will help to better understand the health crisis in the country both structurally and organizationally. Through the results of published work, we present this review highlighted the main point’s issues in the Haitian health system, which will help identify avenues for intervention in a view to change and improvement.


INTRODUCTION
Haiti, known as the first free nation in the world to gain independence from France in 1804, is today considered the poorest country in the Western Hemisphere [1] (Table 1). On the health front, the country reports a chronic structural and organizational crisis dating back more than 30 years. Operating with a limited budget, the MSPP (Ministry of Public Health and Population) has had difficulty providing the necessary health care to the population. As a result, the country has unfavorable health indicators compared to regional or global averages [2]. and two hours or more. Nearly 8 million people, or 72% of the national population, lived within 5 km of a primary care facility offering good accessible care, with a smaller number also living near facilities with good management and organization (51%), good primary care functions (31%) or efficient service delivery (30%).6 It should also be noted that health facility attendance varies across economic well-being quintiles. The percentage of patients brought to a health facility increases from 75% in the lowest quintile to 88% in the highest quintile.

About financial coverage
According to the World Bank in 2017, Haiti's total health expenditure as a proportion of gross domestic product (GDP) was 7.6%, with a per capita value of $ 131, which is much higher than the average for low income countries ($ 93) but well below the average for the Latin American and Caribbean region ($ 1,113). Nevertheless, value for money is low because the level of spending in Haiti is much higher than other countries with similar or lower maternal and child mortality rates, such as Rwanda ($ 125) and Eritrea ($ 51) [6].
The allocation of the government's health budget is extremely low compared to countries in the region. It is less than half the average for Latin American and Caribbean countries [7]. Total health expenditure is estimated at USD 59.5 billion in 2013-2014, made up of donor funds (56.7%), direct payments (30.1%), the government budget (9.7%) and private sector expenditure (3.5%) [8]. This represents a heavy financial burden for almost half (49%) of the population, who claims "having no money" as the main barrier to accessing health care [9]. Households that spend more than 10% of their overall expenditure on health care increased from 9.4% in 2012 to 11.5% in 2013; deteriorating significantly among the economically most disadvantaged quintile from 11.6% to 18.2% over the same period, while reducing the richest quintile from 9.5% to 4.5% [10]. This finding also highlights the problems of low efficiency in Haiti's health sector.
The mechanism for wage payments is another problem, as widespread corruption hinders the proper use of financial resources. In 2018, the Ministry of Health recovered a total of $ 3 million in pay cheque over the previous 10 months by changing the method of payment from a deposit to an employee's bank account to a pay cheque delivered directly to their accounting office's [1].

The health service in Haiti
Availability of services is a problem in all health institutions in the country and current levels of health worker productivity are very low. An analysis of the efficiency with which health inputs are transformed into health services reveals that Haiti has very low technical efficiency scores compared to other low income countries [6]. Clinics are the most inefficient type of health facility and the inefficiency of other types of facilities health centers without beds, health centers with beds, and hospitals In two recent studies published by WHO and the World Bank, they presented the universal health service coverage index for each country and gave Haiti 47 points out of 100, ranking it 139th out of 183 member countries of the United Nations [3]. For the Health Care Access and Quality Index, Haiti scored 32 out of 100 points and ranked 168th out of 195 countries [4]. In 2010, health statistics showed that Haiti's maternal mortality rate was 380 per 100,000 live births compared to a regional average of 68. HIV prevalence was 1,435 per 100,000 compared to a regional average of 315. Tuberculosis prevalence per 100,000 was 296, compared with a regional average of 40. The parameters have, however, changed somewhat in recent years. In December 2014, the MSPP reported that maternal mortality had fallen to 157 per 100,000 births and HIV had increased to 2,200 for men and 2,700 for women per 100,000 [2]. However, they are far from satisfactory considering the benchmarks.
This document presents a few statistical lines that will help to better understand the health crisis in the country both structurally and organizationally. Through the results of published work, we present the main points of weakness in the Haitian health system, which will help identify avenues for intervention with a view to change and improvement.
In a recently published article, Hashimoto describes the 3 main tracks missing in the Haitian health system: geographic coverage, pointing to the problem of access to health care; financial coverage, and the inadequacy of basic health services [1].

Sanitary coverage
In 2013, there were 907 health facilities working in Haiti, less than 40% of which operated under the direct control of the MSPP [2]. Although two thirds of the health facilities are located in rural areas, 125 of the 571 communal sections do not have health services. This clearly presents a geographical limitation to health services, particularly for the rural population. The main reasons for this limitation can be explained mainly by: the insufficient number of facilities, difficulties in accessing facilities and local customs [1].
Haitian authorities found that 37% of the population found a reason not to attend a health institution, and in the majority of cases, distance was the main reason. In only 10% of the cases the institution was located at less than one kilometer from the sick or injured person's home. In 48 per cent of the cases, the health facility was between 1 and 9 km away; for 11 per cent of the sick or injured people, it was about 10 km-14 km away, and almost one third of the sick or injured people had to travel at least 15 km to reach the health facility (31 per cent) [5]. Transport was also the main reason for not attending a health facility. In 18 per cent of cases, the sick or injured person had to walk to the health facility, and almost half of the sick or injured people used to take less than 30 minutes to reach the health facility (49 per cent). However, for 30% of people, the travel time was estimated between one Axler Jean Paul et al.

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follows accordingly. Primary care units are therefore particularly inefficient. Other measures of efficiency at the hospital level, such as bed occupancy rates, confirm the low productivity of hospitals.
Anna D Gage et al. observed that good quality primary care is accessible only to 23% of the population with 46% in urban areas and 5% in rural areas [11]. Approximately 90.6% of the population of Haiti lived within 5 km of a primary health care facility. Compared to other low income countries, Haiti has low coverage rates for basic services. For example, according to Haiti's 2012 Demographic and Health Survey, institutional delivery coverage was 37 per cent the average for low and middle income countries is 70.5 per cent, and the percentage of children under 24 months old who received the three diphtheria, tetanus and pertussis vaccine doses [7].
Health facilities need infrastructure and resources to function. Thus, the poor quality of services and facilities in Haiti reduces the use of services [4,12]. Out of 907 health facilities surveyed in Haiti, only 6% were fully prepared to provide minimum essential services: others were partially equipped with the necessary drugs (13%), equipment (54%) and infrastructure (7%). 1 Of the 38 hospitals that were treating critically ill patients, only 39% had such training [6].
One of the reasons for the inefficiency of the facilities is the low productivity of the staff for example, medical staff see only six patients per day (less than one patient per hour) [13]. Productivity is also negatively affected by absenteeism, which contributes to the waste of approximately $ 3 million per year. A recent study of health facilities in three departments found that medical staff in primary health care facilities work only four hours a day but are actually paid full time (World Bank, USAID and MSPP 2013).
Other key factors contributing to low productivity at the hospital level are poorly functioning referral systems and low utilization rates. The fact that the MSPP allocates 90% of its operating budget to staff costs means that operating budgets are too tight to ensure an adequate supply of essential medicines and equipment.

CONCLUSION
Access to medical care in Haiti remains a financial and logistical obstacle. Difficulty of geographical access often meant a travel day for patients seeking care, while limiting the ability of doctors and hospital staff to get to their place of work. On the other hand, the problem of infrastructure, organization and training leads to disparities in the population where the most vulnerable are the ones who pay the consequences. Investments in the health sector in Haiti should be oriented in the direction of these identified issues in order to rectify at least these 3 parameters.