Haïti and the Health Marketplace: The Results are Perishable

1. Haïti and the Health Marketplace: The Results are Perishable Jo Durham, PhD International Health School of Population Health University of Queensland

2. Haïti and the Health Marketplace: The Results are Perishable One of six country case studies examining the provision of health services in severely disrupted environments

3. In Haiti we found . . The state is so weak (some questioned if the state even existed), it is unable to meet its core obligations of provision of accessible and functional health services and its governance function of regulation making the marketplace unplanned,informal, pluralistic, emergent and inequitable with health reconfigured as a commodity

4. Secondly Interventions have focussed primarily on supply at the expense of demand and the supporting function of governance, further contributing to market failure

5. Outline Brief overview of Haïti Methods Results & discussion Conclusion and further research

6. Haïti Disasters and disease outbreaks, violence, social divisions and political instability, have created a succession of “routinized ruptures” Reflected in HDI (0.454, 158/179) and health and social indicators

7. WHO, http://www.who.int/countries/hti/en/

8. Methods Partly funded by the Danish Ministry of Foreign Affairs, coordinated through the Australian Centre for International and Tropical Health (ACITH) Case study approach: Extensive documentary and policy analysis - peer-reviewed articles, books and “grey” literature In-depth interviews using thematic guide (January and February 2011, N = 45) Thematic analysis and subsequently analysed using a market perspective

9. Health system Public, private, traditional Public & private not-for-profit provides coverage to around two thirds of the population Private sector serves around 10% Traditional “available to everyone”

11. Discussion Emphasis in Haïti has been on the supply side of health care with the gap in state provision filled by the private sector Limited attention has been paid to the demand side or institutional capacity building The presence of internationally subsidised services has reduced demand for public services The inability of the state to regulate the market has led to market failure, and ineffective, inefficient and unequal allocation of resources and ultimately ruinous health outcomes

12. Discussion Emphasis on supply side has undermined capacity of state to fulfil its obligations Has allowed health care to expanded in an unplanned, uncoordinated and unregulated manner & commoditised health Relative over supply of curative services, over-prescription of pharmaceuticals and asymmetrical knowledge between providers and patients Raises questions of transparency and accountability – who are private providers accountable to? Governance dispersed and global

13. Conclusion Reversing fragility and building resilience & adaptive capacity into the health system needs interventions at multiple levels Need to recognise and harness the wide range of players which provide healthcare with analysis including analysis of broader social and political environment Find ways of building demand side capacity to influence the behaviour of consumers

14. Conclusion Further research is needed to better understand how to build demand, e.g. how can community networks be leveraged to shape health systems where the state is weak While not without risks need long-term engagement with state Find ways of influencing providers to understand what incentives would motivate the private sector to self regulate Recognise that program design is likely to be emergent and require new ways of monitoring and evaluation – what works in what contexts for who?

15. Full report http://www.sph.uq.edu.au/docs/Haiti_Final_8May12.pdf

16. Acknowledgements Dr Peter Hill Dr Enrico Pavignani Dr Markus Michael Mark E Beesley, RN Images from global image

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