Strengthening the health system while investing in Haiti.

The devastation brought on by the January 12, 2010, earthquake in Haiti was predictable and indeed predicted—not in time or exact location perhaps, but in consequences.1 To many whose first visit to Haiti came only after the earthquake, the desperate situation of life before remains only a notion; as does the fact that Haiti is truly a place of cultural richness and beauty and, despite its poverty—or perhaps because of it—a place of great solidarity, where in rural life putting your shoulders together to help one another (kole zepol in Haitian Creole) is essentially a national pastime. Now more than a year after the event, there remains much to be done to respond to the needs of those who have survived the earthquake and the devastation (including a raging cholera epidemic) that has followed. As humanitarian projects continue and the government of Haiti moves forward with its response to the cholera outbreak and a proposed 18-month reconstruction plan, it is worth considering how health programs that were successful before the disaster provided both a platform from which to respond and a lesson on how to strengthen the country's health system. Despite years of development aid and thousands of nongovernmental organizations present before the earthquake, Haiti had some of the worst health statistics in the Americas, including the highest infant mortality and maternal mortality rates in the Western Hemisphere. In 2006, the incidence of smear-positive pulmonary tuberculosis (TB) in Haiti was 133 per 100 000 persons and health services reached only 60% of the population, with the rest of the people—largely those living in rural areas—relying on traditional medicine because they lacked (and still lack) access to other services.2 The public sector comprised about 35.7% of the health infrastructure, demonstrating the limited capacity of the government to provide health services. Physicians were largely concentrated in the capital city of Port-au-Prince and in other large towns. In some provinces, there was only one physician for every 67 000 people. Between 2005 and 2008, nearly 30% of health professionals left the country for the US or Canada.1,3,4 The government regularly increased the health budget during this same period, but recent funds were lower in real terms than they were in the 1980s as a result of inflation. All of these factors combined to produce a weak preexisting health infrastructure in Haiti, which, compounded by the acute loss of human resources for health and damaged infrastructure in the earthquake, contributed to the massive loss of life during the time following the initial disaster. Despite these challenges, Haiti's national HIV program had made great strides in the years before the earthquake. First identified in the country in 1981, HIV/AIDS became the leading cause of death in 1999. Haiti was among the first set of grant recipients from the Global Fund for AIDS, Tuberculosis, and Malaria (Global Fund) in 2003, and since then, the country has received two additional grants for HIV/AIDS and one for TB. The US government began funding HIV/AIDS prevention, treatment, and care interventions in Haiti through the President's Emergency Fund for AIDS Relief (PEPFAR) in 2004. The program is considered a success story for scale-up of HIV prevention, diagnosis, and treatment in a resource-poor setting, with more than 19 000 individuals on HIV treatment at the end of 2009. Our organization, Partners In Health (PIH), supports 11 hospitals in rural Haiti that provide HIV treatment and care as well as primary health care services; PIH also receives support from the Global Fund and PEPFAR. Within 10 days of the earthquake, the leaders of Haiti's HIV/AIDS program facilitated an emergency meeting of implementing partners to address critical issues related to the disaster for the program and for people living with HIV. Within weeks, two of the largest organizations involved in HIV care and treatment, including PIH, had accounted for over 95% of their patients on antiretroviral therapy. Some of the earliest public health messages on radio stations after the earthquake were to notify people living with HIV that their medications were available and where they could go for help. Although significant challenges lie ahead, particularly for displaced people living with HIV, the lesson is simple: a program with sufficient human resources, a functional medical records system (with electronic back-up), and a working coordination mechanism pre-earthquake was able to recuperate rapidly and to work on implementing a plan for its own needs going forward. More than the HIV program's ability to “dust itself off,” investment from years past in not just building the program, but in building the health system in which to deliver HIV-related care resulted in PIH's ability to provide a rapid surgical and medical response after the earthquake. Since 2003, funds with the goal of HIV program scale-up have been used to leverage the development of comprehensive health services in the rural Central Plateau and Lower Artibonite Departments of Haiti. A 2009 internal evaluation of our programs in Haiti using mixed qualitative and quantitative methods demonstrated that Global Fund and PEPFAR funding were associated with strengthening of the health system locally including increasing physical space, laboratory capacity, and human resources for non-HIV health activities. Available data between 1998 and 2008 was analyzed and demonstrated that funds initially targeted for increasing access to HIV diagnosis and treatment were successful in increasing attendance at primary care clinics for children and pregnant women, testing for syphilis, and providing vaccinations for children. We found, for example, that in PIH-supported programs, the average annual number of pediatric consultations increased by more than 500% after Global Fund and PEPFAR funding began, as did the number of pregnant women seeking services. This increase was compared with an average 1% increase for pediatrics and 56% increase for pregnant women seeking services at a large general hospital also with Global Fund and PEPFAR funding over a similar timeframe. Polio vaccinations annually increased by an average of more than 300% at PIH sites, compared with 18% at the general hospital site.5 In this instance, the lesson is that investments in health care programs can and should be made with the system as a whole in mind, carefully constructed within the context of national plans and avoiding the errors of vertical projects. In this way, a program created to respond to one crisis (HIV) has the breadth and flexibility and substance with which to respond to a totally different kind of crisis (mass casualties). Organizations and donors new to Haiti's landscape would do well to take stock of the previously successful programs here that invested in the health system, aligned with a national plan, and developed Haiti's own human resources. The opportunity now for Haiti in the context of so much interest and funding and so many organizations involved is for us all to put our shoulders together to create a health system that is greater than the sum of its potentially disparate parts.