Aileen Ye 50042006

Christella Goh 50027653

Mavis Cheng 50027697
Tang Kai Yee 50028431
Vijaya Letchumi.S 50042007

1

Republic of NGOs: The Increasing Privatization of Haitis Healthcare
Introduction
A health system is defined as an organization of people, institutions, and resources to
deliver health services that meet the health needs of its population. Healthcare systems are
usually organized in terms of their (1) components: service delivery, workforce, information
systems, supplies, financing and stewardship, (2) institutions and (3) goals. The healthcare public
sector in a nation is important as it determines its medical capacity and ones access to medical
care, as well as coverage for illnesses treatments and preventive care, contributing to the overall
health outcome. Haiti is becoming known as the Republic of NGOs due to the increasing
privatization of healthcare, with resources from international aid donors being funded towards
Non-Governmental Organizations (NGOs) and diminishing the governments role and capacity
to act in the public sector. In this paper, we will first explore the epidemiology of Haiti before
moving on to the cultural aspects of the Haitian healthcare beliefs. After which, we will discuss
the key problems that Haiti's healthcare system faces and the solutions being employed by the
community to alleviate themselves from a system that cannot rely on its public sector and has too
much dependence on international power structures.




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Part 1: Epidemiology
Demographics
Haiti has a population of 10,173,775 as of 2012 (The World Bank, 2013). The population
mostly consists of the young with majority in the 15-64 age-group (see Figure 1). According to
the Central Intelligence Agency (CIA) The World Factbook (2013), the age structure is as
follows: 0-14 years: 34.6%; 15-64 years: 61.3%; 65 years and over: 4.1%. Haiti has a slightly
larger female population than male population, with the sex ratio of males to females being
0.98:1.00.
Figure 1: Population Pyramid of Haiti 2013(est.)

[Source: CIA The World Factbook (2013)]
The population is mainly split into two ethnic groups: African Blacks; and Mulattos and
Whites. As African ethnic influence is dominant, about 95% of the population are Blacks, with
Mulattos and Whites making up the remaining 5% of the population. Being a still developing
nation, Haiti only has 53% of urban population, while the remaining 47% live in rural areas.

3
Health Indicators
Several indicators can be used to measure the healthcare of Haiti. Indicators such as life
expectancy, infant mortality rate (IMR), and death rate, are used to assess how long a Haitian is
expected to live and an average Haitians chances of survival.
Table 1: Demographic Indicators of Haiti (2011)

[Source: UNICEF (2013b)]
Life expectancy of total population in Haiti has improved from 55 years in 1990 to 62
years in 2011 (see Table 1). Across gender, males have a slightly lower life expectancy of 61
years, whereas females have a higher life expectancy of 64 years (CIA, 2013). Crude death rate
(per 1,000 population) has improved to 9 in the year 2011 from a rate of 13 in 1990. These
indicators show that despite still being a poor country, Haiti is gradually improving and making
slow changes to its healthcare. Despite a high total fertility rate of 3 (see Table 1), infant
mortality rate (per 1,000 live births) still remains at a relatively high rate. It did however, show
improvement by almost half from 99 in 1990 to 53 in 2011 (see Table 1). Male infants also have
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higher chances of dying than female infants, with male IMR being 55 as compared to the female
IMR of 47 (CIA, 2013).
Table 2: Health Indicators

[Source: UNICEF (2013b)]
From Table 2, only slightly more than half of the total population (69%) have access to
improved drinking water sources, whereas a large 31% of the population have trouble getting
proper drinking water. Haiti has a poorer level of sanitation facilities with only 17% of its total
population getting to use improved sanitation facilities. Across these two indicators, a higher
proportion of the urban population gets access to proper drinking water and sanitation facilities
(85% and 24% respectively) than the rural population (51% and 10% respectively). In terms of
immunizations, at a glance from Table 2, Haiti has relatively good immunization coverage for a
nation of its status. Across the various indicators for immunization, more than half of the
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population/infants are covered. However, Haitians are not receiving the care they need in treating
pneumonia and diarrhoea. Only a small proportion of Haitians (3%) with suspected pneumonia is
given antibiotic treatment. Although more Haitians with diarrhoea are given treatment with oral
rehydration salts (40%), more than half of them are still not receiving the treatment they need. In
addition, HIV/AIDS has been an existing health problem. In Haiti, adults have a HIV prevalence
rate of 1.8% (see Table 2). Among the young people (aged 15-24), females have a higher HIV
prevalence (1.1%) than males (0.4%). Males appear to take more prevention against HIV than
females, with more proportion of males having comprehensive knowledge about HIV (40% as
compared to 34%) and use of condom among young people with multiple partners (51% as
compared to 23%).
Figure 2: Death Causes Distribution

[Source: World Health Organization [WHO] (2013)]
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The causes of deaths in Haiti can be mainly split into two categories: Communicable
diseases; and Non-communicable diseases. From the pie-chart in Figure 2, it can be seen that
communicable diseases (e.g. pneumonia, HIV/AIDS, and tuberculosis) are more likely causes of
deaths than non-communicable diseases (e.g. stroke, cancers, and diabetes). Communicable
diseases contribute about half of the deaths (53%) in Haiti, while non-communicable diseases
contribute more than 40% of the deaths. A small proportion of deaths are caused by other factors
such as injuries. Among the non-communicable diseases, cardiovascular disease (e.g. stroke) is
the highest risk factor for death, contributing about 20% of total deaths.
Table 3: Top 50 Causes of Death

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[Source: World Life Expectancy (2010)]
The top three causes of deaths in Haiti are influenza and pneumonia, HIV/AIDS, and
stroke. All three causes add up to about one third (31.7%) of the total deaths (see Table 3).
Diarrhoea is also a prevalent cause of death (7.8%) and especially among children. According to
the Global Health Observatory Data Repository by World Health Organization based on 2008
estimates, across all age groups, infectious and parasitic diseases (e.g. tuberculosis and Sexually
Transmitted Diseases excluding HIV/AIDS) are the most persistent cause of death. Among
children aged 0-14, diarrhoea, respiratory infections and perinatal conditions (e.g. prematurity
and birth trauma) are also leading causes of death. Of which, perinatal conditions killed
proportionally more boys than girls. Among adults aged 15-59 years, HIV/AIDS and
cardiovascular diseases (e.g. stroke) are the leading causes of death, in addition to infectious and
parasitic diseases. Of which, infectious and parasitic disease, and cardiovascular diseases killed
more males than females, while more females died of HIV/AIDS. Among elderly aged 60 years
and above, cardiovascular diseases and cancers are the leading causes of deaths, with more
females dying of cardiovascular diseases than males (WHO, 2011).
Factors
Several factors seem to contribute to the healthcare conditions of Haiti. The main
problem that seems to contribute to the poor healthcare in Haiti is due to the chaotic politics.
Haiti has experienced political instability for most of its history. Being once colonized by the
French, Haiti had a large proportion of slaves. After gaining independence in 1804, it
experienced political coups and instability (Webersik & Klose, 2010). Due to its history, most
Haitians speak Creole, resulting in a communication barrier which made it difficult to expand its
trade with the Europeans and thus affected its agricultural productivity and exports badly. With a
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high population density and poor management, resources depleted rapidly. To make it worse,
Haitis politics was in a mess. It underwent regime changes and military dictatorships for many
years. In the years of rule, none of the leaders or dictators had any interest in developing and
modernizing the nation. Even till recently, continued instability and technical delays prompted
repeated postponements until Haiti inaugurated a democratically elected president and
parliament in May 2006. Furthermore, the massive earthquake in 2010 dealt an even more severe
blow to Haiti, with the already created political chaos hampering basic services and preventing
humanitarian assistance from reaching the vulnerable. With political instability, economic
decline, and having to deal with aftermaths of natural hazards, Haiti is having extreme
difficulties in recovering its economy and solving health problems of the society.
Besides political factor, socio-economic factors also affect Haitis current health
conditions. Population growth of Haiti exposes more people (numerically) to existing health
problems, which affects the nations capacity to cope. Income is also a socio-economic factor
that affects healthcare conditions. More than half of Haitis population live on less than a dollar a
day. The lack of skilled labor and limited employment opportunities caused a high
unemployment rate of about 70% (Webersik & Klose, 2010). These affect the Haitians ability to
afford and access healthcare. The declining economy also shows the low standards of the
healthcare facilities/system in Haiti.
Comparison to Dominican Republic
Dominican Republic is chosen to compare with Haiti as both are neighboring nations that
occupy the same island - the island of Hispaniola. Being in the same geographic location, both
nations are exposed to a similar level of natural hazards such as earthquakes and tropical storms.
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Similarly, both nations also underwent a series of regime political changes, albeit with different
outcomes.
Table 4: Indicators of Dominican Republic (2011)

[Source: UNICEF (2013a)]
On an overall scale, Dominican Republic seems to fare better in healthcare than Haiti.
From Table 4, it can be seen that Dominican Republic has a much higher life expectancy of 73
years (2011) than Haiti, which is 62 years (see Table 1). In addition, Dominican Republic has an
infant mortality rate of 21 (2011), while Haitis infant mortality rate is more than double of that
at 53. In terms of health indicators, more than 80% of Dominican Republics total population has
access to improved drinking water sources and sanitation facilities, as compared to the low 69%
(improved drinking water resources) and 17% (improved sanitation facilities) in Haiti (see Table
2). Despite having experienced times of political instability just like Haiti, Dominican Republic
pulls out stronger and fares better across most health indicators.
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There are several factors that cause the differences in healthcare between Haiti and
Dominican Republic. The first factor is the difference in political trajectories between Haiti and
Dominican Republic, whereby the different political outcomes affect how the nations are coping
in terms of healthcare. As mentioned above, Haiti was once colonized by the French, whereas
Dominican Republic was colonized by the Spanish. Like Haiti, Dominican Republic experienced
political coups and instability after gaining independence. With continual political instability and
economic decline, Haiti is unable to have a proper healthcare system and healthcare policies or
reforms cannot be carried out effectively. On the other hand, Dominican Republic had continued
trade relations with Europe. Since the country has a lower population density than Haiti, it has
lesser pressure on its resources. Although Dominican Republic had similar political
circumstances as Haiti, the country had an effective dictator, Trujilli, who autocratically ruled
from 1930-1961. Unlike Haiti, Dominican Republic was beginning to modernize, industrialize
and engage in environmental protection due to Truijillis influence, thus putting them on the
track towards economic growth (Webersik & Klose, 2010). This positive growth allows better
resources to be allocated to healthcare.
The second factor is the degree of vulnerability to geohazards. Haiti is more vulnerable to
natural hazards than Dominican Republic, resulting in greater economic damages and social
problems (Webersik & Klose, 2010). Not only did hazards claim many lives, thousands of
people also became homeless and this affected living conditions. The aggravated sanitation
problems also worsened existing health problems. In addition, the poor management of resources
further shaped the vulnerability of Haiti against hazards. Comparatively, Dominican Republics
better management of resources helped build higher resilience to natural hazards.

11
Part II: Cultural dimensions of health, disease and healing
Beliefs about Illness
In the Haitian culture, the definition of illness varies from the globalized biomedical
terms. According to WHO/Pan American Health Organization [PAHO] (2010), the cultural
definition of illness in Haiti states that illness is a result of an imbalance of the harmony between
an individual and his or her surrounding environment, whereas biomedical terminology refers to
illness as a disturbance within the body due to a malfunction of the body system. In Haiti, illness
is classified into three main groups: Maladi Bondy (visible or ordinary physical illnesses),
Maladi f-moun mal or maladi diab (invisible, secret or magic), and Maladi lwa (spiritual). They
believe that physical illness can be simply cured by Western medicine, while the Vodou (Haitis
cultural medicine) priests are more apt in dealing with the spiritual and magical healing. The
general medical terminology has similar classification of illnesses, but it regards biomedical
attention as the key aspect of healing practices. The Haitian culture has differing modes of
healing practices as compared to the biomedical culture. For instance, rituals are included as part
of the Haitian healing process, which is vastly different from the biomedical culture where
doctors would first diagnose the illness according to the list of diagnosis in the biomedical
industry.
Moving away from physical illness, when talking about mental illness in Haiti, it is seen
largely as a taboo among people. Research has found that patients of such illnesses prefer to
approach Vodou priests instead of health professionals (Cook Ross Inc., 2010). This suggests
that the religious people in Haiti view mental illness as a spiritual problem rather than a medical
problem. With regard to HIV/AIDS, there has also been research showing that HIV patients
experienced stigmatization in their respective communities even though the population has a
12
high prevalence of the disease (Cook Ross Inc., 2010). Even then, it appears that religion is seen
as the cause of the illness among the community as well as the cause of stigmatization of the
patients. A National Strategic Plan for Preventing and Controlling Sexually Transmitted
Infections and HIV/AIDS for the period 2002 to 2006 was drawn up in 2002 for the Haitian
Ministry of Public Health and Population, where it was highlighted that the religious culture of
Vodou was one of the factors which contributed to the prevalence of HIV carriers in the country,
as the religion practices sexual freedom (Benot, 2007).
Variety of Practices and Beliefs That Are Most Prevalent
According to McShane (2011), religion plays a crucial role in all parts of Haitian life
including health. Vodou or Voodoo, a religion, is widespread in Haiti and is practised by the
majority. In Haiti, the traditional practices of Vodou is not only seen as religious, but can also be
considered as a system of healthcare - including healing practices, health promotion and
prevention of illness, and promotion of personal well-being - just like how many other religions
practise their own forms of healing practices. Illness is interpreted at two levels in Vodou: the
need to create a harmonious relationship with the spirit world (ancestors and gods) and the role
of magic. In other words, it is believed that a person falls ill either due to failure to please the
spirits or due to supernatural powers, spells, hexes or curses. Hence, an individuals health and
illness is dependent on his or her connection to religion and morality.
Vodou is based on a vision of life in which individuals are given identity, power and
protection to mend their health if disordered. In Vodou, the oungan (Vodou priest) and the
manbo (Vodou priestess) are well respected individuals in the community. They lead the
community as they acquire the knowledge of the religion and tradition. In addition, they also
take on medical doctor roles as they are endowed with the power to treat illness. They conduct
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many healing rituals through singing, dancing and most importantly, the music of the drums.
Herbal remedies (herbalists) and spells with the help of lwa (spirit that embody the major forces
of universe) are used in the healing rituals. Thus, Haitians often visit the Vodou priest or
priestess to improve their health (WHO/PAHO, 2010).
Aspects of Social Structure and Culture Affecting the Types and Use of Services
Since most Haitians are highly religious, they tend to seek out traditional medical
services (Vodou priests, priestess and herbalists) more than western medical services. As quoted
in Medical Sociology by Cockerham, people who are part of a close and exclusive parochial
group are less likely to seek medical care if cultural beliefs support skepticism and distrust of
professional medicine (2007, p. 145). In Haiti, the cost of a consultation with the traditional
healers can cost up to a hundred times more than the consultation fees at the medical centres
(Wagenaar, Kohrt, Hagaman, McLean, & Kaiser, 2013). Since Haiti is considered to be one of
the poor countries, it is highly unlikely for many of the rural populations to be able to afford the
medical costs of seeking out the traditional healers. Ironically, these people who earn less than a
thousand goud (Haitis currency) per month are still willing to pay for the most expensive
treatment due to their cultural beliefs. Even certified medical doctors and medical institutions
form allies with religion and spiritual leaders to get people to seek medical treatment. Haitians
trust these religion and spiritual leaders more willingly than health professionals or doctors.
Hence, it is evident that Haitians give large importance to their culture and often rely on their
inner spiritual and religious strength to deal with their medical problems rather than to seek
professional medical help.
Family, as an individuals first significant social network, has a huge influence on
Haitians behavior in obtaining medical care as well. According to Sloand, Gebrian, and Astone
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(2012), caring for one another and all families in the community is a cultural phenomenon, a
key component of group values and beliefs, which is part of the Haitian culture in rural areas.
Most of the Haitians live together in communities where they would be able to help one another
in times of crisis. As Suchman mentioned, close and ethnically exclusive social relationships
tend to channel help-seeking behaviour in individuals (as cited in Cockerham, 2007, p. 145).
Likewise in Haiti, families living in one community not only help one another but also influence
one another in regards to medical issues. Therefore, family influence is a key factor in Haitians
medical decisions.
Choosing Among Healers: How the People Decide Among the Variety of Healers Available
Help-seeking behaviors vary greatly depending on factors such as location, religion and
social class. Since Haiti experiences political crisis, location proves to be one of the obstacles
when Haitians need to go in search of medical help. Just as Benot found in her study, the HIV
patients in many of the poverty-stricken towns have emphasized [that] it was impossible for
them to leave home in search of medication during the weeks when violence was rife (2007).
This would suggest that professional medical centres were mostly located at the more urban
areas, where the rural population might not be able to keep up with the travel into urban areas.
Additionally, with almost a third of the population not having access to proper drinking water
even though there are proper medical centres scattered across the country, western medicine does
not seem to help the health issues in Haiti. Even a HIV patient would be unable to be compliant
since he or she would have difficulty gaining access to clean water and sanitation facilities. In
the rural regions, keeping up with the planned regular doctor visits would be rather tough,
especially in impoverished towns (Benot, 2007).
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Another study done by Wagenaar et al. (2013) shows that the top three reasons for the
selection of the choice of medical aid among patients with mental distress in rural regions are
they give the best care, they make me the most comfortable and understand me, followed by
they are closest [in proximity] to me. However, it was noted in the study that close to a third of
the participants chose religious care, while a quarter chose hospitals and another quarter chose to
approach family and close friends. It appeared that Haitians would select their medical providers
based on the type of illness or disease they are suffering from, such as patients of mental distress
approaching the Vodou priests for help, while HIV patients seek the aid of medical professionals.
As Benot (2007) mentioned in her study, HIV-positive patients regard themselves as
victims of m sida (AIDS death), which simply means their symptoms are the result of
sorcery, in order to avoid being stigmatized. Benot also noted the trend that HIV patients
would continue to consume their medication despite being deeply rooted to their religion.
However, it was still reported that their illness caused them to experience rejection from their
own religious groups. This could also be one of the reasons why HIV patients who approached
medical aid tend to change their perception of their traditional religion. As the study shows,
when patients obtain the anti-retroviral drug and join the various support groups, they also often
move away from their respective religious practices or alternative healing (Benot, 2007).
It was also found that the elites of the Haitian society do not consider Vodou as their
religion (Benot, 2007). This appeared to suggest that the elites have greater access to medical
aid as compared to the lower social class, where religious practices are very much prevalent
among the poorer communities. Thus, Vodou is more widely used amongst the general Haitian
population as compared to western medicine.

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Part III: Who is helping and how?
Description of Haitis Healthcare System
Figure 3: The Haitian Health Systems Status Quo

[Source: Harvard University and NATO Haiti Case Study (2012, p. 9)]
Haitis current health policy framework is contained in the countrys Strategic Plan for
Health Sector Reform 2004. Due to socio-economic and political instability, the country has not
been able to make significant progress toward this goal, including approving drug laws that were
put in place in 1948, 1955 and 1977. Responsibility for public health and infrastructure falls
under the Ministry of Public Health and Population (MSPP), of which the Ministry of Health
(MOH) is a subdivision. MOH leadership is represented at federal, department (regional) and
community level. However, there has been an absence of healthcare legislation, leadership and
administrative implementation. With regard to the distribution of healthcare in Haiti, the doctor
to population (per 1,000 people) ratio is 0.25 (in 1998) but in rural areas such as Chabin, the ratio
could go as low as 0.02 (WHO, 2013a; WHO 2013b). Human resources in health are severely
limited and also under WHOs recommendation of 25 doctors per 10 000 people (2.50). The
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strength of Haitis health workforce has been its community health workers. In 2010, the total
expenditure on healthcare in Haiti was US$464 million. Total expenditure on health per capita
was $94 in 2011 and out of this $94, $41 was paid by the government. Total expenditure on
health as a percentage of GDP (Gross National Product) that year was 7.9% (WHO, 2012; WHO,
2013b). The national budget for healthcare garners only an estimated 4% of the national budget -
below regional average or USD $65 per head per year according to Active Learning Network
for Accountability and Performance in Humanitarian Action (ALNAP) (Harvard University and
NATO, 2012). In a country where more than 70% of the population live on less than two dollars
a day, there has been significant decrease in use of healthcare services. Only about 1500 public
service employees receive social insurance, which covers healthcare costs at public facilities.
Private insurance is a rarity. Many with the means to travel seek healthcare in the U.S., Canada
and other Latin American countries, thus contributing to foreign rather than local health systems.
Haitis current healthcare services are structured into three levels: (1) First level with
over 600 first-response health centers with and without beds and 45 secondary community health
centers, (2) second level consisting of 10 district hospitals, and (3) third level consisting of six
university hospitals, with five of them in Port-au-Prince (Global Emergency Relief, 2013). These
services are provided or supported by various actors from the public sector, the private for-profit
sector and the mixed and private non-profit sector - 37% of the 722 healthcare establishments are
under the Ministry of Health (Organisation of the Christian Force of Bayonnais [OFCB], n.d.).
The private sector, especially the non-profit providers such as the "Republic of NGOs", the
Cuban brigade and a few faith-based and charity clinics, play an extremely important part in
Haitis healthcare - over 70% of the health budget in Haiti is funded externally by these NGOs
under the coordination of WHO, with more NGOs per capita than any developing country apart
18
from India. Bilateral aid, such as doctors from the Cuban Brigade, also plays a big role.
According to Harvard University and NATO (2012), there was an estimate of 10, 000 NGOs in
the country prior to the earthquake and they provided about 75% of health services to the Haitian
people. Their relative strength in comparison to the Haitian government and their long standing
presence in the country is what caused Haiti to earn the informal designation of the Republic of
NGOs.
Amongst the Republic of NGOs are Partners in Health (PIH), Doctors Without Borders,
or Mdecins Sans Frontires (MSF), and the International Medical Corps (IMC). PIH has just
recently completed the construction of a new public flagship hospital in Haiti - Hopital
Universitaire de Mirebalais (HUM). The construction of HUM, which also serves as a national
teaching center, goes hand in hand with PIHs aim of bringing good medical care to the poor.
PIH believes that primary healthcare is essential as health is a right and hence, should be made
available to everyone. Along with the completion of HUM, PIH aims to bring quality care to the
people by establishing long-term partnerships with local sister organisations such as Zanmi
Lasante (PIH, 2013b). One other NGO presence in Haiti is MSF. MSFs original focus in Haiti
was to provide emergency response, but it has since switched to providing more routine
specialist medical services such as pediatrics, mental health, reconstructive surgery etc. (MSF,
2011). The IMC on the other hand, aims to encourage its trainees to return to their native
communities to serve using skills they have developed - the idea of teaching-a-man-to-fish. This
distinguishes IMC from other well-known NGOs such as PIH and MSF, which focus more on
alleviating symptoms instead of empowering locals to care for themselves (Zuckerman, 2011).

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Key Problems Faced by the National Healthcare System.
The key problems faced by the national healthcare system are (1) healthcare financing and the
competition brought about by international aid response to local healthcare providers and the
healthcare infrastructures already in place, (2) an inadequate and underpaid workforce, (3)
disruption to medical supply routes as a result of the earthquake, and (4) the cholera outbreak
and food and water insecurity.
(1) Healthcare system financing and the effect of international aid response on the healthcare
infrastructures already in place
Haiti is currently $641 million in debt, largely owed to the International Monetary Fund
(IMF) and the Inter-American Development Bank (IDB). The inability to service its debt in
addition to Haitis history of frequent regime changes, political violence, corruption and weak
governance has caused mistrust in its government and created barriers for Haitis foreign
investment and development. Foreign aid and funding is mostly channeled through NGOs
instead of direct funding to its public healthcare system. Farmer (2010) stated that, at the time of
the 2010 earthquake, 80% of all aid to Haiti and 90% of all U.S. aid was channeled through
NGOs and contractors who set up their own health, water, education and agricultural programs,
with little reference to government oversight and thus did not help build the capacity of the
Haitian public institutions that must provide health and public services over the long term.
According to Farmer, U.S aid policies have seesawed between embargoes and efforts to bypass
governments, including elected ones not to Washingtons taste. Neither the international
community nor the United States provided credible long-term financial investment in Haitis
20
public sector (2010). Currently, the World Bank has canceled Haitis debt and hopes are that the
IMF and IDB will follow suit.
In discussing the relationship between politics and foreign aid, Farmer argues, Meddling
by the West in Haitis internal politics has contributed to the countrys chronic political
instability. Periodic withholding by the U.S. of direct assistance to the Haitian government
including democratic but leftist governments and U.S. vetoes of initiatives by international
organizations to channel aid directly through the Haitian government have steadily eroded the
capacity of the public sector to provide basic social services. Additionally, in a testimonial to
the U.S. Senate Foreign Relations Committee in 2003, Farmer says, de facto prohibitions of
development aid to the government of Haiti that the US promoted in forums in which it held
influence, including the Inter-American Development Bank of which at the time of Farmers
testimony was effectively blocking four loans to Haiti from the Inter-American Development
Bank for primary healthcare, education, potable water, and road improvement because they
did not condone the outcome of Haitis 2000 elections, which brought the left-leaning Aristide
back to power.
Haitis leaders have a limited influence over the planning and activities of the numerous
foreign actors, including NGOs, in the health sector. Their ability to control NGOs not
complying with national health plans (for e.g. Beaubian, 2013: Ministry of Healths pill
distributions against elephantiasis) or agreements particularly for underserved populations is
severely limited because the NGOs enjoy the support of the communities they serve and their
foreign donors. According to Harvard University and NATO (2012), in the absence of effective
state policies, foreign assistance has sought to fill the void, but a clear strategic and
comprehensive policy approach does not exist. Funding fluctuates in accordance with political
21
circumstances, donor strategies vary, and the government has little influence over the use of
funds.
International healthcare and relief efforts can compete with the local workforce and affect
the balance of healthcare systems already in place. The huge presence of NGOs in the country
has inadvertently created tensions with the local healthcare system. The availability of high
quality care from foreign doctors put enormous pressure on the private local doctors. Local
private clinics were being driven out of business because they do not provide free service
(Adams, 2010; Wilentz, 2010). Health providers and aid workers, including governmental
stakeholders, also do not have sufficient coordination at national and international political levels
in achieving a common goal. Humanitarian communities in Haiti lack a shared health
information picture and a coordinated health service delivery system that optimizes their
combined efforts in tandem with the Haitian government. Each organization acts alone and the
large differences in capacities of bigger organizations (mostly foreign) compared to smaller
organizations (mostly local and faith or community based), cause a striking disconnect
between the international community and Haiti. ALNAP (Harvard University and NATO, 2012)
reports that larger international NGOs were able to coordinate more successful than smaller
grassroots organizations who faced constraints in time, money, modes of communication and
access to coordinate with other like-minded organizations. The fact that a huge proportion of
Haitis health resources are not under the control and management of the state but are instead
under the donors and NGOs (Kenyon, 2012) created an imbalance of power between the
government and NGOs. International NGOs contributed great efforts in addressing the problems
they saw but failed to work with the government to build up the public sector. Additionally,
international humanitarian NGOs do not deploy their resources or staff to work within national
22
institutional frameworks and humanitarian funding is not directed at building the capacity of the
public health, public education and water sectors.
(2) An inadequate and underpaid workforce
The uneven distribution of work and the discontent among local healthcare workers
whose livelihoods have been negatively affected not only by the earthquake but also the
humanitarian efforts to alleviate its effects have contributed to the upheaval of the Haitian
healthcare sector. Frequent disruptions of health system financing have provoked strikes by
employees of the public system and stripped health officials of the ability to oversee or enforce
regulation of the public sector. There are insufficient trained medical staff and many doctors
leave the country to escape political violence and to procure better pay, resulting in brain-drain.
There are fewer than 2000 doctors in the entire country, and most of them are based in Port-au-
Prince, where less than a quarter of Haitians live (Farmer, 2004). Historians report that even
though 264 doctors graduated in the decade following the regime of Dr Francois Duvalier Papa
Doc
1
, only 3 stayed in the country. In 2003, a newly opened medical school, University of
Tabaree was opened but ended up being converted into a military base for U.S. and other foreign
troops. There is a lack of strategic planning for human resource requirements especially with
regard to a genuine policy for staff retention in an environment that is strongly influenced by the
private sector and NGOs that offer better opportunities such as more attractive salary. After the
2010 earthquake, the World Bank assumed the role of fiscal agent for the Haitian government
and temporarily took over payroll functions for federal employees. However, sustained donor
funding for direct budget support has been difficult to maintain. Several unique arrangements

1
President of Haiti from 1957 - 197. He was a Vodou doctor and leader of a cult who ruled with a rural militia
known as the Tonton Macoute. He was initially known for fighting diseases, earning him the nickname, Papa Doc.
23
with organizations such as the American Red Cross to fund the salaries of the public sector
health employees materialized but were fraught with administrative and bureaucratic difficulties.
(3) Disruption to medical supply routes as a result of the earthquake
Haitis health supply system is entirely operated by external actors - in the 1990s PAHO
started a pharmaceutical and medical equipment supply system, called the Programme de
Medicaments Essentiels (PROMESS). The PROMESS warehouse in Port-au-Prince supplied all
public facilities as well as many NGOs. Harvard University and NATO (2012) states that
medical supply chains for Haitis public health system were tenuous prior to the earthquake, but
these supply routes, inclusive of the airport were disrupted once the earthquake occurred.
Additionally, supplies that were eventually dropped off at the airport and seaport but were
electronically inventoried proved problematic because it could not be shared over a network. The
combination of disorganized supplies and disjointed and incomplete inventories along with the
velocity and volume of supplies caused the system to be backed up and it was extremely
challenging to ensure supplies arrived at their intended recipient. The existing PROMESS supply
chain was also affected because tons of rubble blocked most of the exits from the city. The
warehouse inventory was also largely unmarked and lacking in inventory sheets and manifests,
adding to the difficulty of distribution.
(4) The cholera outbreak that followed the earthquake
In 2010, Haiti faced two major disasters, the earthquake and the cholera epidemic, posing
a significant challenge to Haitis health system. The earthquake destroyed not only the countrys
governance and infrastructure but also damaged the facilities and human resources of the
humanitarian organizations, specifically to the leadership of the United Nations Stabilization
24
Mission in Haiti (MINUSTAH) after evidence indicated that the Nepalese UN battalion could
have brought the bacteria into the country. Prior to that, cholera was not historically endemic to
Haiti and hence they had no experience dealing with it. Terrified residents were frustrated with
the lag in medical care and not only directed their anger toward MINUSTAH but violently
protested the opening of a 400-bed cholera clinic because of fears that it would bring more
cholera into the region (Harvard University and NATO, 2012). The increased violence and
instability hampered response resources and impacted food security because many farmers
feared that the water irrigating their rice fields could have been infected. The concentration of
efforts to deal with the epidemic distracts from efforts to strengthen Haitis healthcare system.
Additionally, patients avoided clinics where cholera patients were treated and the bodies of
deceased cholera patients remained uncollected by families and undertakers, because the clinics
lacked the sanitation facilities to handle waste from cholera patients. The environmental
contamination impact has also been extensive and the cholera bacteria is feared to have
contaminated the water table in considerable depth, leading UN deputy special envoy to Haiti, Dr
Paul Farmer to declare that cholera is likely to become endemic in Haiti because it is the most
water insecure country in the world. This is likely to have resulted from environmental
vulnerabilities, most notably the extensive deforestation for the purposes of charcoal production,
Haitians main source of fuel. Only an estimated 2% of Haitis forests remain and this has led to
a fragile environment with landslides and floods along with the hurricane vulnerable and erosion
prone coastline.
Grassroots Movements and Community Health Workers
A grassroots movement differs from an NGO in that it is driven by the politics and social
conditions of a community. In Haiti, some grassroots are initiated by locals and others are
25
created with the help of aid organizations who want to empower locals. Grassroots groups and
community health workers are important to Haiti because they are able to reach the chronically
poor majority. In Haiti, grassroots movements seek support to replace the need for a government
funded public sector and alleviation from a system dependent on international support. Their role
is to fill that void and start helping Haitians take control of empowering themselves, putting in
place local initiatives and programs that could work with and possible be absorbed by the Haitian
State. Their belief is that it is critical that Haitians be directly linked to the rebuilding of their
country and be in control of the process in order to create a country that provides for all its
people. What is unique about the community based programs initiated by these groups is that
they work hand in hand with the preservation and continued education of their own language and
culture where the concern is the increasing cultural homogenization. Grassroots movements in
Haiti contribute to health not only by providing basic healthcare but by addressing problems like
food security, deforestation and poverty.
Haiti Marycare is one such organization that has a micro level approach, working from
the ground up and using low cost approaches that are scalable. Currently it has initiated three
projects: clean water wells, which trains local men how to dig wells thus providing clean water
for villagers, doliv tree farming, re-planting a tree indigenous to Haiti and acts as a medical
supplement, and micro credit in partnership with Bank Fonkoze, to provide credit loans that help
Haitians out of poverty. Konbit Sante, a health care group that is a beneficiary of Direct Relief
and dedicated to addressing common delays to obstetric care, is training and supervising forty
traditional birth attendants as well as establishing a dispatch and transportation system. After the
earthquake in 2010, many frightened Haitians flocked to the Papaye Peasant Movement (MPP)
located at the Central Plateau area of Haiti, a national grassroots movement that organizes and
26
empowers small farmers to improve their living conditions. MPPs goals are to help Haitians
regain food security, contribute to sustainable natural-resource management, promote alternative
energies as well as advocate for womens rights and building people-centered rural communities
(uusc4all, 2011).
Community health workers (CHW) are members of a community who are trained by
healthcare organizations to provide local communities with basic health and medical care. Task
shifting of primary care functions from professional health workers to community health
workers is a means to make more efficient use of human resource to improve the health of rural
populations at an affordable cost. In developing countries such as Haiti, where there is a shortage
of health professionals, community health workers fill in the gap, especially in underserved
regions. One such region in Haiti is Leger, where Ame Sade community health workers help the
community with problems such as dehydration, diarrhoea, vaccinations, prenatal and postnatal
care, and family planning (with committees for breastfeeding support and condom distribution).
These community health workers are recommended members of the community who either have
to travel by foot, horseback or negotiate narrow ravines in order to reach the community. Some
of these towns look up to their healthcare providers as pillars or leaders of their communities
(USaidVideo, 2011).
In Milot, their hospital - the Sacre Coeur Hospital - provides leadership, healthcare and
employment, sustaining the communities around them. According to Dr David Butler, Chairman
of CRUDEM (Center for the Rural Development of Milot), Its the only form of government
the people of Milot have. When the cholera epidemic struck Haiti, Dr Previl, CMO of the
hospital, gathered townspeople in the church saying to them, Listen, this cholera epidemic that
is coming Im very scared of it. If Im scared you should be scared. He gathered the
27
townspeople in the church where he hung up a bed sheet and projected pictures of what to do and
what not to do to prevent the spread of cholera. Butler says, If he hadnt done that, no one
would have done that. Theres no television, they really depended on the hospital to help them in
this crisis that they were facing (HNMCMedia, 2013). Besides leadership, some grassroots
initiatives can rehabilitate locals that have been traumatized by chronic (displaced by a natural
disaster) and life events (exposure to constant violence). One such project, Papaye Peasant
Movements Road to Life yard in its Eco village in Central Plateau, is supporting survivors in
creating sustainable livelihoods and foster peoples control over their own food (uusc4all, 2011).
The Road to Life yard involves using recycled old tires to create tire gardens, which need little
water to sustain them during the dry season. The food produced by five tires can produce enough
to feed an entire family, and an extra five tires can produce enough food to bring in a household
income of two hundred dollars. Symbolically, the tires hold special significance as during Haitis
turbulent past, tires were burned in the streets to create roadblocks where gangs would attack
travellers. They were also used to create Haitian neckties, by dousing them with gasoline and
placing them around victims who were then burned alive. What previously was an instrument of
death now brings new life to Haiti.
Grassroots and community health workers are an important part of the nature of healing
in Haiti. Healing is not just receiving medical attention but finding a purpose for and a way to
rebuild lives and improve life chances. Being able to help oneself is empowering and completely
different from physiological healing. To be part of a community and part of a purposeful
movement in which efforts are not blocked is equally important in creating a healthy and hopeful
social atmosphere.

28
Conclusion
In conclusion, weaknesses in other systems (political strife, foreign political interests,
debt, divestment of aid to the public sector, medical supply chains, water and food security,
endemic preparedness and economic resource management) affect Haiti's health system.
International initiatives to develop venues on how to contribute to a comprehensive approach are
not being fully supported by public sector officials and civilian actors in development
communities because they do not fully support the existing plans put forth by the Haitian
government and compete with the local livelihood and social infrastructure. The role played by
NGOs is vital in heathcare and disaster relief; however they have to work within the existing
infrastructure instead of retarding it. The role that grassroots organizations and community health
care workers play is extremely important as: they are able to reach parts of the population located
away from urban areas as well as connect with them culturally, providing them with leadership, a
sense of community and teaching them to empower and educated themselves. Lastly, health is
not just physiological. Where NGOs and WHO address medical needs, it is the social aspect of
health that grassroots and community health organizations address.








29
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