Inisyativ Nasyonal yo, Gwo Defi yo, ak Wòl Aktivite Kolaborasyon yo: Sante Inivèsèl an Ayiti ap Avanse

NATIONAL I N I T I AT I V ES, KEY CHALLENGES, AND THE ROLE OF COLLABORATIVE ACTIVITIES UHC Haiti Moving toward Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized re Authorized 1990 2015 1990 2015 Haiti’s snapshot 1 Existing national plans and policies to achieve UHC 2 Key challenges on the way to UHC 4 Collaborative efforts to accelerate progress toward UHC 6 References and definitions 8 42.2 2000 2015 59 64 61.5% 47.4% 35.8% 80.1% 28.9% 47.9% 33.6% 9 per day 7.5% 37.9% 78% NO DATA 25% NO DATA NO DATA NO DATA 43.1% Haiti’s snapshot 146 69 625 359 76% 1 Moving toward UHC: Haiti Maternal Mortality Ratio (WHO) Per 100,000 Live Births Under-Five Mortality Rate (WHO) Per 1,000 Live Births 70 (SDG target) 25 (SDG target) UHC Service Coverage Index (SDG 3.8.1, 2015) Score (for capacity) # of indicators (out of 48) Health results More deaths in lowest than highest wealth quintile per 1,000 live births Life Expectancy at Birth (WHO) LMIC average Care-seeking for symptoms of pneumonia Dropout rate between 1st and 3rd DTP vaccination Access barriers due to treatment costs Access barriers due to distance Treatment success rate for new TB cases Provider absence rate Caseload per provider Diagnostic accuracy Adherence to clinical guidelines 5 4 3 2 1 No capacity Limited Developed Demonstrated Sustainable NO DATA NO DATA NO DATA NO DATA NO DATA See page 8 for References and Definitions. Performance of service delivery – selected indicators (PHCPI, 2012-2015) Wealth Differential in Under-Five Mortality (PHCPI, 2012) Results of Joint External Evaluation of core capacities for pandemic preparedness Catastrophic OOP health expenditure incidence at the 10% threshold (SDG 3.8.2) 48 % NO DATA 48 + 52 + C Haiti Moving toward UHC: Haiti Moving toward UHC: Haiti 3 2 Existing national plans and policies to achieve universal health coverage (UHC) SERVICE DELIVERY REFORMS Since 2011, Haiti’s Ministry of Health (MOH) service delivery model has included a focus on community care. Family Health Teams have been introduced to jointly deliver essential health care, particularly in poor, underserved, and remote areas. For example, vaccination activities were recently added to the Community Health Worker (CHW) curriculum, one of a range of services as part of the generalized CHW model. This model exists alongside “specialized” CHWs who implement vertical programs, as well as local CHW networks managed by nongovernmental organizations (NGOs) or faith-based organizations. The government would like all CHWs to deliver a broad range of services, but not all partners are willing or able to change their approach. With the objective of achieving an efficient service delivery model, the government is leading a dialogue with partners to reduce fragmentation, foster coordination, increase coverage, and eventually move closer to UHC by increasing access to affordable care through sustainable mechanisms. These efforts include developing a basic essential benefits package to be provided through an Integrated Health Services Network and several ongoing pilot interventions, with MoH’s leadership and support from international partners. HEALTH FINANCING REFORMS Haiti faces challenges in terms of equitable and affordable access, financial protection from excessive payment of user fees, catastrophic health expenditures, and an overall reduction in the availability of resources, both from domestic and external sources. Since there is not yet an official health financing policy, the government and partners are reforming the financing system to reduce financial barriers to care, improving planning in the use of resources, establishing stronger donor coordination mechanisms, and aligning government and partner priorities. In the context of declining resources, the government and partners are discussing different pathways to improve the efficiency of the health system and increase fiscal space and innovative policies to reduce financial barriers to care. With donor assistance, Results-Based Financing (RBF) programs have increased accountability, efficiency, and performance. Health providers commit to providing a certain number of services, are evaluated by an external agency, and receive payments for reaching certain performance standards. Initial results are promising, but further assessments over a longer implementation period are required. GOVERNANCE REFORMS There are several ongoing efforts to strengthen stewardship and governance of Haiti’s health system. The MoH Organizational Law is currently under revision. In 2017, the MoH reinvigorated coordination with partners through regular Table Sectorielle roundtables, which bring all partners together to discuss strategic issues and work toward sustainable solutions. In May 2017, the President established a Commission for Health Sector Reform in Haiti, intended to produce recommendations within a year. Finally, in September 2017, the MoH launched the ‘Assises Nationales de Santé’ to analyze health sector challenges in a participatory manner and update the Strategic Plan, looking forward to 2030. UHC, governance, service delivery, and human resource development were key topics. 76% of women declared they had problems in accessing health care due to the cost of treatment, 43% due to distance (DHS 2012). Moving toward UHC: Haiti Moving toward UHC: Haiti 5 4 Key challenges on the way to UHC CHALLENGES IN SERVICE DELIVERY Access and coverage of essential health services. Haiti faces substantial challenges related to maternal and child health. Antenatal care, in-facility births, and DTP3 vaccinations are all much lower than the averages for the Latin America and Caribbean region. Quality of care. In part, quality of care is affected by an insufficient health workforce and poor infrastructure. The number of medical staff (physicians, nurses, and midwives) per capita in Haiti is low compared to WHO recommendations. Haiti has substantially less basic infrastructure and equipment than other low-income countries, contributing to a relatively low proportion of health facilities meeting international standards. At the center of efforts to improve quality, there is a need to strengthen health care and health services management processes and for human resource (HR) development (number of workers, skills mix, distribution, performance evaluation, and incentives). Among other efforts, targeted improvements in the workforce and investments in basic infrastructure and equipment will be essential to improve quality of care. Pandemic preparedness. Existing plans for infectious disease control have primarily focused on cholera, which has plagued Haiti in recent years. A National Plan for the Elimination of Cholera in Haiti (2013–2022) has been developed. However, a Joint External Evaluation (JEE) of International Health Regulations (IHR) core capacities has not yet been conducted. One important aspect of pandemic readiness that has been identified is the need to further strengthen the CHW model in Haiti, and to increase its coverage. THE STATE OF HEALTH FINANCING Overall funding for health. Government funding for health is 1–2% of GDP, lower than in most other low-income countries (LICs); the government spent just US$13 per capita on health in 2014 (WHO, 2016). In the 2016–17 budget, the government’s contribution to the health sector has further declined, leaving very limited resources for drugs, supplies, and other operating costs. Haiti has been highly dependent on external funding for health, particularly after the devastating 2010 earthquake which displaced many people, damaged infrastructure, and shifted scarce resources toward the delivery of emergency services. Furthermore, 90% of external funding is off-budget, creating inefficiencies in the system and difficulties in coordination between the government and partners. Financial barriers. People in Haiti face two important barriers to accessing care: cost and geography. Out-of-pocket expenditures have increased to approximately 35% of total health spending (WHO, 2016) and almost 93% of facilities charge user fees (WB, 2017). With over half the population living in poverty, many people are unable to access care. In addition, many people seek help from traditional healers, who charge high fees without necessarily improving health outcomes. Also, many people do not access care because they lack transport to distant health facilities. Financial protection schemes. Haiti has experienced several natural disasters, political instability, and declining external funding, thereby preventing the articulation of clear policies on financial protection for vulnerable populations. At present, very few people benefit from financial protection schemes, and most of the population continues to pay out of pocket for most services. GOVERNANCE CHALLENGES Coordination among stakeholders. Improved coordination between key actors in the Haitian health sector is needed to increase progress toward UHC. Public and private stakeholders must better align interventions and funding, and efforts are needed to foster the participation of civil society organizations, academia, and associations of health professionals to increase awareness and build consensus around key approaches to reach UHC. Accountability. The large amount of external funding that is off-budget (90% of the total) is not linked to specific outcomes or reporting, making it difficult to assess how effectively resources are utilized. Furthermore, there are few mechanisms to track the performance of providers. Although the RBF program is currently strengthening provider accountability, this does not cover the whole country. While providers are required to report health indicators through the Health Management Information System (SISNU), there are no clear incentives for accurate or timely reporting, aside from the RBF program. Unexpected costs from natural disasters. Haiti has experienced recurrent natural disasters, including a recent earthquake (2010) and major hurricane (2016) that significantly affected infrastructure, the delivery of essential supplies, and the number of functioning health care facilities. Furthermore, natural disasters increase the risk of infectious conditions, as seen with the increase in cholera cases in 2016, which claimed 70 lives and infected over 5,000 people within a few weeks. Both natural disasters and subsequent proliferations of infectious diseases divert existing resources from regular care toward the management of emergency care. Developing national and sectoral plans to effectively address recurrent emergencies are key steps to addressing this challenge. Moving toward UHC: Haiti Moving toward UHC: Haiti 7 6 Collaborative efforts to accelerate progress toward UHC EXISTING INITIATIVES SUPPORTED BY EXTERNAL PARTNERS External partners are engaged in Haiti to build national capacity and strengthen the health system. The Tokyo Joint UHC Initiative, supported by the government of Japan and led by the World Bank (WB), in collaboration with the Japan International Cooperation Agency (JICA), United Nations Children’s Fund (UNICEF), and the World Health Organization (WHO), is supporting the government of Haiti and strives to accelerate progress toward UHC. This support will enable strengthening of nationally-led strategic health systems to achieve UHC, as well as pandemic preparedness. Partners are providing both financial and technical support to the government, aiming to address key challenges in maternal and child health, community health strategies, health financing, infrastructure, and overall coordination mechanisms. The government and partners are jointly engaged in innovative approaches such as the RBF program to address key UHC bottlenecks. PLANS FOR FUTURE COLLABORATIVE WORK Policy and Human Resources Development (PHRD)-funded advisory support The activities under the Tokyo Joint UHC Initiative fall within two broad categories: moving toward UHC and pandemic preparedness. Several activities will contribute to achieving UHC: (i) enhancing service delivery capacity at the health provider level; (ii) improving access to maternal health care through a focus on lower levels of care; (iii) costing and prioritizing the national Health Sector Plan; (iv) analyzing supply- side deficiencies, particularly in lower-level health facilities; (v) mobilizing resource efforts specific to UHC; and (vi) supporting governance and accountability. In the area of pandemic preparedness, efforts will focus on: (i) assessment of existing pandemic plans and pandemic responsiveness, including cholera; (ii) technical assistance for costing and prioritizing pandemic preparedness activities within the National Health Sector Plan; (iii) resource mobilization for pandemic preparedness; (iv) support for governance, accountability, and appropriate institutional arrangements; and (v) enhancement of community-level health care for pandemic preparedness and response. Furthermore, the joint work will closely cooperate with other investments in health, such as the Global Fund and Gavi, to contribute to health system strengthening. Considering that other sectors, such as nutrition and water and sanitation, compose the foundations of heath for all, challenges in these fields also will be considered under the joint work. The PHRD support will also help increase the impact of current and future World Bank investments in the health sector, in particular under IDA18. Among other objectives, this will help identify suitable approaches for moving toward UHC and effective pandemic preparedness. Haiti has experienced recurrent natural disasters, including a recent earthquake (2010) and major hurricane (2016) that significantly affected infrastructure, the delivery of essential supplies, and the number of functioning health care facilities. Moving toward UHC: Haiti 8 Co-authored by: Photo credits: Page 3 & 5: Dominic Chavez / World Bank Page 7: Christelle Chapoy / World Bank UHC Service Coverage Index (2015) – WHO/World Bank index that combines 16 tracer indicators into a single, composite metric of the coverage of essential health services. For more information: WHO/World Bank (2017). Tracking UHC: Second Global Monitoring Report. Catastrophic out-of-pocket (OOP) health expenditure incidence at the 10% threshold (Single data point, year varies by country) – WHO/World Bank data from Tracking UHC: Second Global Monitoring Report (2017). Catastrophic expenditure defined as annual household health expenditures greater than 10% of annual household total expenditures. Results of the Joint External Evaluation of core capacities for pandemic preparedness (2016/17, year varies by country) – A voluntary, collaborative assessment of capacities to prevent, detect, and respond to public health threats under the International Health Regulations (2005) and the Global Health Security Agenda. 48 indicators of pandemic preparedness are scored using five levels (1 is no capacity, 5 is sustainable capacity). https://www.ghsagenda.org/assessments Life Expectancy at Birth (2000-2015), Maternal Mortality Ratio (1990-2015), Under-five Mortality Rate (1990-2015) – WHO Global Health Observatory: http://apps.who.int/gho/data/node.home Wealth Differential in Under-five Mortality (Single data point, year varies by country) – Indicator used by the Primary Health Care Performance Initiative (PHCPI) to reflect equity in health outcomes. For more information: https://phcperformanceinitiative.org/indicator/ equity-under-five-mortality-wealth-differential Performance of service delivery – selected indicators (Single data points, years vary by country) – Indicators used by the Primary Health Care Performance Initiative (PHCPI) to capture various aspects of service delivery performance. PHCPI synthesizes new and existing data from validated and internationally comparable sources. For definitions of individual indicators: https://phcperformanceinitiative.org/about-us/ our-indicators#/ References & Definitions (page 1 indicators)