INSTITUTIONAL COORDINATION IN HAITI PROBLEMS AND STRATEGIC RESPONSE

1. INSTITUTIONAL COORDINATION IN HAITI PROBLEMS ANDSTRATEGIC RESPONSE Dr. M Duperval (MSPP)/ Dr. J André (MSPP-IDB) VII Regional Forum, Quito, Ecuador, 30 October 2007

2. 8.65 million inhabitants • 39% urban pop (LAC = 77.5%) • 46% access to drinking water (LAC = 88%) • 28% access to sanitation (LAC = 74%) • Gini 0.66 (LAC = 0.53)

3. Some facts … • Lowest health indicators in the Region • Life expectancy at birth: 53 years in decline compared to the ‘90s • Maternal mortality: 630 per 100 000 on the rise compared the ‘90s • Infant mortality: 57 per 1 000 in decline since the ‘90s • High poverty level and weak level of development in the country • Little access to care (cost recovery in a context where 2/3 of the population lives on US$2/day) • Lack of HR (2.3HR per 10 000 inhabitants)   

4. CHALLENGES FOR INSTITUTIONAL COORDINATION • Available services are poorly developed, fragmented, and segmented, with little capacity to offer quality care

5. CHALLENGES FORINSTITUTIONAL COORDINATION … • The base of the health pyramid is made up of 50% private/mixed providers and 50% public providers • Lack of health insurance plans • Lack of coordination of interventions in the field • Unequal allocation of resources in the field • Unequal distribution of services (from a geographical standpoint) • Inability to monitor the establishment of health institutions (until last year) • Inability to monitor its capacity to deliver quality services that meet standards

6. CHALLENGES FORINSTITUTIONAL COORDINATION … • Sector’s financing system: irregular and unmonitored: multitude of separately financed agencies, each with its own agenda and often out of sync with MSPP objectives • Directed external financing • Own management modalities (sometimes with parallel management structures) • Situation not compensated by an integrated planning framework • There are as many strategic plans as programs • There are as many planning, monitoring, and evaluation frameworks as financing agencies • Gap created by the State’s weak regulation capacity andcoordination (weak governance capacity) • Capacity limited to assuming the steering role functions

7. CHALLENGES FOR INSTITUTIONAL COORDINATION… • Responses at two levels of the system

8. INSTITUTIONALCOORDINATION MECHANISMS Operational responses • Community Health Units (UCS): • Integrated primary health care system • Community Plans, Integrated Departmental Plans (PDI), and Annual Operating Plan (POI) • Integrated participatory planning process • Health Institution accreditation process • Standardization of interventions and quality improvement Strategic responses • Roundtable on Consensus-building in Health • interagency coordination with the MSPP • Forum for the Realignment of Health Sector Reform(FRRSS) • development of a long-term strategic vision under MSPP leadership

9. 1. UCS: INTEGRATEDPRIMARY HEALTH CARE SYSTEM Operational Level • The basic package of services (BPS) is considered a key step that provides health services to the population through the UCS based on: • Equity • Transparency • Justice • The basic package of services is a minimum set of essential integrated interventions, selected from among the most cost-effective, to whichthe State is committed, based on its resources, that are available to the entire population with the purpose of raising the general health status. • BPS is universal (not targeted): it defines the benefits andservices that the State has the capacity to deliver

10. HEALTH PYRAMID AND INTERVENTIONS • Goal: Meet the population’s health needs • Structured by level • Integrating care, services, and benefits • Increasing Equity (universal access) Third level: University/Specialized Hospitals _________________________ Second level: Departmental Hospitals _____________________________________ First level: HCR SSPE THE COMMUNITY

11. ORGANIZATION OF SERVICES ucs First-level health institutions (public, mixed, private, non-profit) • 2nd level HCR 150-250,000 inhab. • 1st level SSPE 10 beds/10,000 inhab.

12. ELEMENTS OF THE BASIC PACKAGE OF SERVICES • Integrated management of childhood illnesses • Pregnancy, delivery, and reproductive health care • Management of medical/obstetric emergencies • Basic oral care • Fight against communicable diseases • Availability of and access to essential drugs • Participatory health education • Environmental health, availability of safe drinking water

13. 2. COMMUNITY PLAN, PDI, POI Operational Level • Objective: • Have a tool to help plan interventions on an annual basis • based on fixed needs with an upward focus from the community level to departmental and national levels to evaluate performance and optimize resource allocation • Stakeholders involved • MSPP officials, department directors, UCS, elected local representatives, the community • (in effect since 2006-07)

14. 3. Accreditation Process for Health Institutions Operational level • Objectives: • Standardize interventions • Improve the quality of services available to the population • Develop specific institutional strengthening plans • Stakeholders involved • Central and departmental MSPP officials • Institutions involved: • Public, mixed, and private • (in effect since January 2007)

15. 4. ROUNDTABLE ON CONSENSUS-BUILDING IN HEALTH Strategic Level • Objective: • Align the interventions of the principal financing agencies with MSPP guidelines and plans • Stakeholders involved: • MSPP and principal bilateral and multilateral cooperation/financing agencies (USAID, CIDA, French Cooperation, IDB, World Bank, UNAIDS, UNICEF, UNFPA, PAHO/WHO …) • Monthly meetings (since March 2007)

16. 5. Forum for Realignment of Health Sector Reform (FRHSR) Strategic Level • Goal: Strengthen MSPP’s role as leader of the health sector’s transformation process • Objectives: • Evaluate the achievements of the reform process • Develop a tool that will give the MSPP a comprehensive view of the challenges and progress of the reform • Realign the health sector reform, as necessary • In the coming years, implement the responses to the challenges identified in the PSNRSS • Provide the MSPP with a tool for social dialogue and communication about the reform with the Haitian population and society and other countries that are also committed to the health sector reform process • Forge intersectoral partnerships

17. 5. Forum for Realignment of Health Sector Reform (FRHSR) Strategic Level • Stakeholders involved: • MSPP Central Bureaus and MSPP Departments • Parliamentary Representatives, the Presidency, and the Office of the Prime Minister • Representatives of the Ministries of Finance, Women, Planning, and Social Issues • Representatives of bilateral and multilateral cooperation agencies, global associations (national and international NGOs) • Medical and economic societies • Academic sector: Deans of the Faculties of Medicine…

18. Problems of the FRHSR DECENTRALIZATION • Distribution of the attributes and responsibilities (DDCC, DDDD, UCS): What legal framework? • Innovative ways to collect payment • Financing for extended coverage • Adequate payment methods and incentives HUMAN RESOURCES FINANCING • Available human resources: Quantity and type? • Geographic distribution of HR: Where to assign available HR? • HR education and training: What type of doctors? What profile of nurses, etc.? • Architecture of incentives to retain HR: How to motivate personnel? • Quality of care: Develop standards • Monitor recommendations in the accreditation processes • Revitalize hospital networks and SSPE networks: Modernize infrastructure. BETTER HEALTH SERVICE DELIVERY VISION: DEVELOPMENT OF THE PSS extend access to basic health services for the 565 community sectors, starting with women and children • GOAL (END RESULTS): IMPROVEMENT OF THE POPULATION’S HEALTH STATUS • (example: MDGs, reduced MM, etc.) • INTERMEDIATE RESULTS • GREATER EQUITY • CONTRIBUTION TO STABILIZATION AND THE SNCRP • STRUCTURING AND LEGITIMIZATION OF THE STATE BOLSTERING OF GOVERNANCE AND LEADERSHIP • LEADERSHIP FUNCTIONS • Leadership • Regulation • Orientation of financing • Guarantee of Insurance • Harmonization of service delivery ESSENTIAL PUBLIC HEALTH FUNCTIONS

19. Expected outcomes of the FRHSR • 4-5 workshops to put the solutions to the problems that impede the transformation of the Haitian health system into effect (duration: one year) • Availability of data that permit adjustments to PNS and PSNRSS • Recommendations on actions the MSPP should take so that stakeholders in health are aligned with PSNRSS • Operational solutions on the period 2007-15 for the major challenges identified for the PSNRSS • Harmonized vision of stakeholders on their contributions to the implementation of the PSNRSS and subsequent alignment of their actions • Monitoring tools to facilitate the MSPP’s role as promoter and director of the health sector reform process in Haiti

20. Expected outcomes of the FRHSR … • Communication tool to disseminate information about the importance of the reform and its progress in Haitian society, emphasizing the following points: • The role of health in the restructuring of the State and its positive effects in terms of bringing peace and stability to Haitian society • The importance of developing the PSS to improve the living conditions of the population and make headway in meeting the MDGs • The relationship between poverty, reductions in inequality, improvement of the population’s health status, greater productivity and competitiveness, and higher economic growth • The role and importance of civil society and community participation in implementing, protecting, and maintaining the achievements of the reform

21. CONCLUSIONS • The challenges that Haiti must facein the coming years are critical for the future development ofthe health system and the very development of the country • The responses designed are an attempt to aliviate the situation at both the operational and strategic level • Proper advantage should be taken of the opening created by the inauguration of the Preval government (2006) and the relative stabilization of the country to promote the changes that are needed at the State level and among the stakeholders who intervene in Haiti’s health sector (approaches need to be innovative)! • The role of the technical and financial cooperation agencies in support of the MSPP will be key to the success of the reform under way • The efforts and political commitment on the part of the authorities will undoubtedly be a key factor in the success of the process

22. THANK YOU FOR YOURATTENTION! MERCI DE VOTREATTENTION! MESI ANPIL!