The tree provides shade but scant respite from the heat. Chantal, four months pregnant, has just returned from washing her family's clothes in the nearby river.
Her small village, just twenty houses and a single dirt road located about 60 kilometers north of the capital Port-au-Prince, has no health facilities of any kind. The nearest health post (staffed for two hours a day by a high school graduate) is an hour's walk away while the nearest health center is two.
In Haiti, only about a third of births take place in a health facility, so encouraging women to attend prenatal visits and to give birth in facilities requires a special focus from government and donors.
Two decades earlier Chantal's mother gave birth to five children, including Chantal, on the dirt floor of her hut alone. Her husband sat in the next room waiting for her to be finished. Two died due to preventable complications during delivery.
Despite this, Chantal sees no reason to deviate from this well-worn tradition, but has been convinced by a matrone –a midwife and village health advisor of sorts- to allow her to assist with the delivery. She will collect between US$ 1-2 for her services.
Conversely, all deliveries in health facilities are free, a national policy in Haiti to encourage women to make use of them. Health systems in any setting are replete with perverse incentives, encouraging inappropriate or undesirable behaviors.
For example, matrones justifiably fear losing their minimal compensation if women were to heed the advice and attend free consultations at these health facilities. Other barriers include tradition, transportation and poor quality of care.
Any one is powerful in itself, but when combined they pose a significant challenge to governments pondering how to reduce preventable deaths and improve the health of their population.
Highest maternal mortality rate
With the highest maternal mortality in the Western Hemisphere a Haitian woman has a 1 in 37 chance of dying from maternal causes during her childbearing years. Child mortality in Haiti is three times the Latin American average, with children under five at high risk from contracting preventable illnesses such as diarrhea and pneumonia.
So how to attract Chantal, her newborn and her family to use the facilities' free maternal and child health services? Improving the quality is one answer. Changing the behavior of service providers is another. But for once, the answer is not necessarily to inject more money.
By North American, European or South-East Asian standards the funds financing the Haitian health system are minuscule. For Haiti, the available funding is, at this moment in time and at this level of organization of the system, acceptable. The real focus therefore must be on vastly improving governance and management to build a system that is accountable for results.
The patient must be the starting point, relentlessly managing the system for results –- i.e. providing better health outcomes for people. Patients should be encouraged to make use of health services, facility staff must benefit from increased compensation and suitable working conditions, demands on their time for non-clinical purposes should be kept to a minimum and, perhaps most importantly, the link between the population and the system regulator (i.e. the government) must be restored.
Multiple issues with healthcare
There are multiple issues with Haiti's health system, ranging from financial and physical barriers to quality healthcare, to the broken social contract and other intractable problems. Services also suffer from overburdened, undertrained, undercompensated and therefore underperforming health staff. Addressing these all these matters requires a new approach.
Improving the coverage and quality of maternal and child services can begin to be addressed with results-based financing. This should incentivize widening the provision of essential services and improving quality of care to create lasting behavior change among service providers and repair the health staff-patient relationship.
But before this can happen both the Haitian government and its donor partners must uphold their respective responsibilities, be bold and take calculated risks. For the former this means reforming the civil service, fully assuming its leadership role and tackling graft.
For the latter, it's taking the long view: making resources available to strengthen governance systems, and taking a firm line against intransigence and obfuscation. It also means providing direct funding to allow the government to play its regulatory and stewardship role.
In Haiti, the Ministry of Health is looking to introduce a new approach to results-based management through the delivery of evidence-based, high-impact and cost-effective health and nutrition services, provided in part at facility level and in part in the community. To do this, vendors – both public and private-- would be contracted to provide services, receiving a bonus once the target number of patients treated at an acceptable level of quality has been reached.
This approach will be supported jointly by USAID and the World Bank. The success of this approach, however, depends on governance and management of the system. And ultimately building a health system that is leaner and much better performing.
