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Haïti and the Health Marketplace: The Results are Perishable

Jo Durham, PhD International HealthSchool of Population Health University of Queensland

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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

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

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In Haiti we found . .

Secondly

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

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Outline

Brief overview of Haïti

Methods

Results & discussion

Conclusion and further research

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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

Total population 10,174,000

Gross national income per capita (PPP international $)

1,180

Life expectancy at birth m/f (years) 61/64

Probability of dying under five (per 1 000 live births)

70

Probability of dying between 15 and 60 years m/f (per 1 000 population)

258/223

Total expenditure on health per capita (Intl $, 2011)

94

Total expenditure on health as % of GDP (2011)

7.9

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

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

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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”

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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 outcomesCRICOS Provider No 00025B

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

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

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?

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Full report

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

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Acknowledgements

Dr Peter Hill

Dr Enrico Pavignani

Dr Markus Michael

Mark E Beesley, RN

Images from global image

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Selected References Bloom, G., & Standing, H. (2008). Future health systems: Why future? Why now? Social Science & Medicine, 66, 2067-2075. Bloom, G., Standing, H., & Lloyd, R. (2008). Markets, information asymmetry and health care: Towards new social contracts. Social Science & Medicine, 66, 2076-2087. Bloom, G., Standing, H., Lucas, H., Bhuiya, A., Oladepo, O., & Peters, D. H. (2011). Making health markets work better for poor people: The case of informal providers. Health Policy and Planning 26, i45–i52. Cammack, D., McLeod, D., Menocal, A. R., & Christiansen, K. (2006). Donors and the ‘Fragile States’ agenda: A survey of current thinking and practice. Report submitted to JICA. London: ODI.Caple James, E. (2010). Ruptures, rights, and repair: The political economy of trauma in Haïti. Social Science & Medicine, 1, 106–113. Timmermans, S., & Almeling, R. (2009). Objectification, standardization, and commodification in health care: A conceptual readjustment. Social Science & Medicine, 69, 21–27. Tschumi, P., & Hagan, H. (2008). A synthesis of the making markets work for the poor (M4P) approach: UK Department for International Development (DFID) and Swiss Agency for Development and Cooperation (SDC).Zanotti, L. (2010). Cacophonies of aid, failed state building and NGOs in Haïti: Setting the stage for disaster, envisioning the future. Third World Quarterly, 31(5), 755-771.

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