Haiti - Situation note on the population, health and nutrition sectors

Docuent of The World Bank ]FOt oMcAL uSE ONLY Report N.. 5699-CRG HAITI SITUATION NOTE ON THE POPULATION, HEALTH AND NUTRITION SECTORS May 31, 1985 Population, Health and Nutrition Department IThis gcu.eu it a a mtxfArtma dlsrbujom and may be used by rec4ipiens mly ini the performance of t*ei oBdal di. s _mnmts may nt ohewie be dEsdoed withou Wol Bank au}b _m-.  CURRENCY EQUIVALENTS (as used in this report) Currency Unit = Haitian Gourdes US$ = G$5 GOVERNMENT OF HAITI FISCAL YEAR October 1 - September 30  FOR OMCAL USE ONLY HAITI SITUATION NOTE ON THE POPULATION. HEALTH AND NUTRITION SECTORS TABLE OF CONTENTS Page No. ACRONYMS SITUATION NOTE ON THE POPULATION, HFALTH AND NUTRITION SECTORS . . 1 Sector Status . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Policies and Programs. . . . . . . . . . . . . . . . . . . - . 3 Sector Finance . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Problems, Issues, Options . . . . . . . . . . . . . . . . . . . . 7 Intersectoral Issues . . . . . . . . . . . . . . . . . . . . . . . 10 Donor Coordination . . . . . . . . . . . . . . . . . . . . . . . . 12 Concluding Note . . . . . . . . . . . . . . . . . . . . . . . . . 12 Tables and Figures . . . . . . . . . . . . . . . . . . . . . . . 13 MAP This report was prepared from information gathered during a sector review mission conducted in August/September 1982 by Mr. W. P. NcGreevey. A previous report prepared by Mansgement Sciences for Health for the World Bank provided mucb of the necessary background material. That report is on file at the World Bank. J. Allman provided recent data and material to update the report in February-March 1985. This doument has a tricted distribution and may be used by recipients only in the performance or I ir offKia dutiets contents may not otherwise be discsed without World Bank authorization.  ACRONYNS WA PCo - Agence d'approvisionnement de pharmacies communautaires, Agency for Supplying Conmmnnity Pharmacies AOPS - Association des oeuvres privies de sante, Association of Private Health Organizations DON or EDE - Bureau de nutrition, DSPP, Bureau of Nutrition, see DEEM CANE? - Centrale autonome 3etropolitaine d-eau potable, Metropolitan Water Supply Company, Port-au-Prince CAT - Campagne anti-tuberculose, Campaign Against Tuberculosis CERN - Centre d&iducation et de rxhabilitation nutritionnelle, Nutrition Rehabilitation Center DRF - Division d-bygi&ne familiale, MSPP, Division of Family Hygiene, see DEFN DEPN - Division d-hygiene fauiliale et nutrition (DHMN), Division of Family Hygiene and Nutrition DSPP - D4partement de la sante publique et de la populaticn, Department of Public Health and Population, see 'iSPP EEC - Communaute economique europeenne, European Economic Community KARZA - Engineering Company Societe d'ingenierie HAS - ESpital Albert Schweitzer, Albert Schweitzer Hospital HFS - Enquete haitienne de la fecondite, Haitian Fertility Survey IRSI - Institut haitien de statistique et informatique, ex-Institut haTtien de statiatique (IRS) Haitian Institute of Statistics and Computer Sciences, formerly Haitian Institute of Statistics (IHS) MSPP - Ministere de la sante publique et de la population, Ministry of Public Health and Population, formerly DSPP ONAAC - Office national d'alphabetisation et d'action communautaire, National Office of Adult Education and Coammnity Development REDS - Rural Eealth Delivery System Project, PSPSS Projet de systeme de prestation de soins de sante en riilieu rural SNEH - Service national des endemies majeures, ex-Service national d'eradication de la malaria., National Service Against Major Endemic Diseases  ELM Situation Note on the Population. Health, and Nutrition Sectors 1. In 1985 Haiti ranks 18th on the Bank-s list of 28 Low-income countries (per capita product = $320 in 1983). It is one of the poorest in the world. Between 1960 and 1982 per capita income grew 0.6 percent per annum and its population density increased from 164 to 179 per square km., despite significant emigration. In rural areas, farm implements and production techniques remain those of two centuries ago. 2. Haiti ranks poorly in terms of life expectancy at birth (53), infant mortality (120 per 1,000 live births in 1984, according to the HSPP) and percentage of children with second-or-third degree malnutrition (27.3 percent). Its crude birth rate (36) and total fertility rate (4.6) are comparable to countries of similar income level in Africa. Over one-quarter of Haitian women did not breastfeed their infants during the most recent birth interval and 90 percent of deaths among children, 1-4 years of age, is caused by malnutrition and diarrheal diseases. Sector Status Population 3. The total population of Haiti is over five million according to the 1982 Census, and is now growing about 1.8 percent per annum. Port-au-Prince, with a population of 750,000, is ten tines larger than Cap-Baitien, the second largest city. Over 15 percent of persons born Haitian, about one million persons, now live outside the country. The World Bank estimates that total population will grow to 7 million by the year 2000 and 13 million by the year 2050. With more rapid fertility and mortality decline than is now projected, population in the year 2050 could be held to 10 million. A recent Bank report on the agricultural sector calls attention to declining agricultural resources in relation to population; the population-resource balance in rural Haiti will grow increasingly unfavorable unless effective measures are taken to slow population growth. 4. Fertility is only moderately high, in part because of subfecundity associated with the country's poverty. There is widespread knowledge of modern contraceptive techniques, but only five percent of married women were found to be using modern methods of fertility control in a 1983 survey. Pilot experiments demonstrate considerable demand for family planning; the high levels of knowledge of modern methods, and the widespread use of traditional but ineffective contraception, both suggest a context favorable to the introduction of modern, effective methods. The World Bank estimates the unmet need for contraception to be between 13 and 30 percent of all eligible women.  -2- Health 5. The death rate has fallen somewhat in Haiti, from above 16 per thousand population in the early 1970s to about 13 currently. That level is much higher than that which prevails in the rest of Latin America. Similarly, life expectancy is ten or more years less than among Haiti's neighbors in the Caribbean. Outside Port-au-Prince there is but 1.4. physicians for each 10,000 persons. As a result, only a fraction of people who need treatment receive it. Preschool children are sick about half the time; 80 percent of this illness is diarrhea. The vast majority of illness and death in Haiti is related to undernutrition and to infectious disease which could be p=evented by immunization. 6. Infant mortality is high and higher in Port-au-Prince (about 150 per thousand live births) than in the countryside (about 120), in part due to migration toward that city and in part due to deteriorating water supply and sanitation conditions there. The most common causes of death and morbidity are diarrheas and gastroenteritis, tetanus, measles, tuberculosis, malaria, intestinal parasites, pneumonia and respiratory diseases, typhoid and poliomyelitis. Infant deaths are due principally to diarrhea and pneumonia. 7. With respect to adult morbidity, malaria is the most frequently reported cause of illness, followed by pneumonia, bronchitis, diarrheas, and malnutrition. Typhoid, syphilis, intestinal parasites, and respiratory tuberculosis are diagnosed about half as frequently as malnutrition. Other common causes of ill health are anemia, infections of the ear, eye or skin, complications of childbirth and postpartum problems, along with complaints requiring abdominal surgery. Nutrition 8. Malnutrition is one of Haiti's most serious health problems; according to the 1978 Nutrition Status Survey between a quarter and half of all Haitian children suffer from second- or third-degree malnutriton on the Gomez scale of weight for age. About 30 percent of rural children and 48 percent of urban children are anemic. Poverty, food shortages, droughts and floods and feeding practices (only one meal a day, bottle feeding without potable water) all contribute to malnutrition. Feeding practices may explain the excess of urban over rural infant mortality. 9. Pilot projects in Haiti have confirmed the synergism between undernutrition, gastroenteritis, and broncho-pneumonia, the latter two being identified as the leading causes of death. Preschoolers whose weight for height was more than two standard deviations below the mean had double the prevalence of fever and diarrhea of those who had grown normally. These facts demonstrate that curative approaches to health problems are undermined by lack of food.  -3- Water and sanitation 10. Potable water is available to only a minority of households. The fourteen urban systems do not treat water and, witb the exception of a few project areas assisted by external donors, rural areas depend on polluted streams, pits and shallow wells. Less than 3 percent of the urban population have household sewer connections, and only 13 percent have an adequate means of sewage disposal. Projections for the year 2000 foresee that only 8 percent of households in Port-au-Prince will have sewer connections. Urban slum dwellers live in overcrowded conditions without potable water and sewage disposal; their environment makes good health difficult to achieve. Policies and Programs Population 11. The outlines of a population policy appeared in the five-year plan, 1981-86, published by the Government of Haiti. It contains neither fertility-reduction targets nor family planning service delivery goals. In 1984, the President of the Republic of Haiti stated his government's continued concern with rapid population growth, especially the constraints that high fertility pose in regard to social and economic progress. He called ror a reduction of the crude birth rate to 20 per 1000 by the year 2000, fertility of three children per woman, a crude death rate of 8 per 1000, an infant mortality rate of 50 per 1000 and a life expectancy of 65 years. These guidelines are reflected in the New Orientation of the Department (now Ministry) of Public Health and Population (DSPP) announced in 1982. 12. The Division of Familv Hygiene (DHF) of DSPP began family planning work in the early 1970s and shifted in 1977 to a non-clinic orientation, including mobile teams, commercial retail sales of contraceptives and use of community agents. DEF established a commurity development section in January 1979. Contraceptive distribution increased between 1979 and 1982 thanks in part to cooperation witb the Haitian army. In 1983-84, a pilot project using SNEM (the endemic disease control service) volunteers in Hiragoane also produced dramatic increases in use of family planning in this area. 13. Family planning outreach efforts at the DHF were reduced in 1983-84 since the regions and districts were expected to play a major role in service delivery. DHF was to assume a normative rather than an implementing role. Lack of coordination during the implem6ntation of this change led to reduced family planning service delivery. Both the 1983 DEF Annual Report and the 1983 contraceptive prevalence survey indicate very lov levels of contraceptive use in 1983.  -4- Health 14. The New Orientation, a health policy enunciated by the Ministry of Public Health and Population (HSPP) for the period 1982-86, emphasizes primary health care as the strategy to reach the MSPP-s objectives. It identifies six priority areas for ministry action: (1) Diarrheal disease control; (2) immunization against communicable diseases; (3) tuberculosis control; (4) improvement of nutritional status; (5) maternal- child care and family planning, and (6) malaria and endemic disease control. According to the New Orientation, and its revised and corrected June 1984 version, special attention will be given to each of the priority areas during a specified period of time. Thus, as a test case of this approach, the diarrheal disease control program was launched nationvide in July 1983. Using social marketing and the mobilization of a broad range of health. community, commercial and development personnel, this program led to widespread knowledge of oral rehydration, considerable use of commercially available packets of oral rehydration salts, and reduction in diarrhea cases presented for treatment at health facilities. 15. Malaria has increased sharply in Haiti in the past several years. From 41,252 cases recorded in 1979, there were 72,750 cases reported in 1984 according to official data. A 1980 evaluation of SNEK by USAID urged a return to a policy of containment to replace the unvorkable policy of eradication. The 1984 mid-term malaria program evaluation mission stated that the figures for malaria cases were underestimated. The mission recommended expanding the number of voL inteers from the current 7,000 to 18,000. 16. MSPP will focus on improving immunization coverage in 1985. Tuberculosis, malnutrition, and family planning are scheduled for special attention in the years ahead. Decentralization, regionalization and development of the referral system are administrative measures now being taken to improve program efficiency. Nutrition 17. Unlike the sectors of population and health, responsibility for nutrition is not consolidated in a single ministry. NSPP, the Ministry of Agriculture, and the Ministry of Plan all play roles in nutrition activities. Perhaps as a result of the dispersion of responsibilities there is no general nutrition policy guiding government programs in this area. 18. The Division of Nutrition of DSPP offered nutritional rehabilitation to several thousand children in 1980, a tiny fraction of all those presumably needing care. Nutrition centers were filled virtually to capacity. However, rehabilitation was costly and did little to prevent recurrence of malnutrition. A new rural health delivery service project follows a comprehensive, integrated approach to preventive nutritional care including growth monitoring and education. The curative  -5- approach of past nutrition action programs is gradually being replaced by a grovth-monitoring and surveillance program which forms part of the rural health delivery system (REDS) project. This preventive-care program envisages timely, targeted, low-cost interventions which could result in cost-effective nstional nutrition programs in the future. 19. The Division of Nutrition was merged with the Division of Family Hygiene in Jannary 1984, becoming the Division of Family Vygiene and Nutrition (DHFN). Results of the growth monitoring activities conducted in 1982 and 1983 in the South region are being evaluated, and plans are being made to implement the approach in collabor-ation with regions and districts. ProRram Facilities 20. There are 467 population, health, and nutrition facilities in 1985, 85 of them hospitals and health centers with beds, for many of which the occupancy rate in 1982 vas less than 50 percent. In 1985 there are about 622 physicians employed by the DSPP; over half of these are located in Port-au-Prince. Thus, areas outside the capital had a ratio of 1.4 physicians for 10,000 people. Over one-fifth of all government employees work for MSPP; the ministry is, after the Ministry of Education, the second largest employer in Haiti. 21. Private health establishments, many of them run by externally funded private voluntary organizations, make up almost 50 percent of the health facilities in Haiti. Most of these facilities are located in isolated rural areas, and many of them serve the poor and needy. Cooperation and ^ division of labor between them and the government has begun recently. An important step was the establishment of the Association of Private Health Institutions (AOPS) in April ,82". AOPS members have agreed to adopt the priorities and norms of MSPP. The ministry in turn is recognizing the responsibility of private institutions to provide health services in specified areas of the country. 22. AGAPCO, the Agency for Community Pharmacy Supply, is an administratively self-contained program of the MSPP that has been established for the purpose of procuring, distributing and selling low cost generic drugs on a nationwide basis. AGAPCO sells 80 items at regulated prices through over 130 community and institutional pharmacies, the first of which opened in September 1982. The revenues from sales are reserved for the purchase of replacement stock and payment of the programs's operating costs. There may be a potential for eventual financial self-sufficiency. AGAPCO drug supplies at clinical facilities have improvemed the quality of health services. By maintaining an adequate drug supply, AGAPCO is attracting more patients to existing facilities and lowering the treatment cost per patient.  -6- Sector Finance Sources of Finance 23. Population, health and nutrition services are financed in essentially similar ways, and they are treated together in this discussion. Eighty percent or more of public expenditures in these three sectors are devoted to health, at most twenty percent is spent on population programs, and less than five percent on nutrition programs. Greater exactness is not possible because of the overlapping nature of maternal and child health and diarrheal control programs which are related to all three sectors discussed here. Three sources and modes finance can be identified: (1) Households pay directly to providers; (2) tax revenues pay for the current operating expenses of MSPP and international donors pay for the bulk of the ministry's development budget; finally, (3) private and public external funds pay for current operating expenses of many private clinics, particularly in rural areas. 24. In light of Haiti's overall poverty, the country's expenditures for population, health and nutrition are substantial. It 1981, health related expenditures amounted to 4.7 percent of GNP, about US$15 per person. The government's share of sector expenditures is split half-and- half between tzx revenues and rternal grants. Private individuals directly finance nearly 60 percent of health care received. Some 99 registered private and voluntary organizations operating over 200 facilities provide a large but indeterminate share of sector resources. External Assistance 25. The principal donors in these sectors, USAID, IDB, WHO/PAHO, UNICEF, and UNDP/UNFPA, provided about US$8 million in 1980 and similar levels of assistance in more recent years. IDB has supported construction of hospitals and health posts. USAID and UNFPA support DHFN population programs. UNICEF and WHO assist in strengthening health delivery. USAID is also assisting the rural health delivery system and organization and management improvement for MSPP. Budgets of the programs the different donors support were handled separately by vertical programs in the recent past. There is still insufficient coordination in planning assistance. 26. Some 99 private and voluntary organizations make a substantial contribution to population, health, and nutrition programs in Haiti. Their dispensaries are often in isolated, rural locations accessible to the most needy. Since 1982 the Association of Private Health Institutions, AOPS, has worked closely with MSPP. This positive development should be encouraged; it offers the prospect of specialization by level of service in which MSPP could provide adequate secondary-level hospitals to which patients from the private dispensaries and clinics could be referred as necessary.  -7- Problems. Issues. Options Efficiency and Equity 27. The last five years have witnessed major efforts to introduce basic primary healt'I care interventions throughout the (SPP system. Decentralizatioi, regionalization,the expansion of community health workers and the strengthening of private and volunteer participation in health care, have been major accemplishments. Nevertheless, the most urgent problem in these sectors is still the low level of efficiency in providing basic services. In population, cost per user is exorbitantly high, coverage is low, and unmet need for family planing is double or quadruple current use of modern methods. In heal.h, curative care is costly, facilities are understaffed, underequipped, and hence underutilized; most people who need services cannot get them. In nutrition, curative approaches have proven too costly, preventive programs have moved little beyond pilot efforts, and Government has dispersed responsibility among too many agencies. 28. Similarly, in spite of a major rural health delivery effort, equity is also of concern because of the significant rural-urban and regional disparities in service availability which still exist. The geographic distributiou of services dispensed through HSPP is inequitable: too much is spent in the Port-au-Prince area, too little benefits rural Haiti. Inequity and lack of coverage cannot be corrected without greater efficiency. Extension of coverage within current budgetary restrictions will require giving up some services, achieving greater efficiencies, or some combination of the two. 29. Expenditures on population, health, and nutrition strvices by the government were 16 percent of central government expenditure (that is, excluding state-owned enterprises) in 1981. That share is far higher than the average for low-income (2.9 percent of central government expenditure) or even for middle-income economies (5.3 percent). It may be unrealistic to expect the government to spend any more of its resources in this sector. Thus greater efficiency in resource use in each of these three sectors is essential as a prelude to improving equity a-od extending coverage. Population Issues and Options 30. Of the three sectors, population should be assigned highest priority for several reasons. Contraceptive prevalence has fallen and must rise to meet population policy goals. Total forest area is shrinking by five percent per annum. Population growth is an immediate, as well as a longer-term, development problem, as illustrated by the flight from the island's poverty as farm opportunities shrink with soil erosion and tree cutting.  -18- 31. Until the 1980s, the Government of Haiti shoved little concern for population growth and the unfavorable balance between resources and population. More recently, the government has been more emphatic on the need to slow population growth. Fever pregnancies can have beneficial impacts on both health and pGpi3lation growth. A strong population policy which specifies the measures to be taken to reduce fertility rates and population growth is vitally needed at this time. 32. The MSPP has recently established a Directorate of Population to work with other key ministries, such as Plan and Agriculture, concerned with future trends in population dynamics and nutrition. There is clearly a need to reverse the decline in family planning service delivery that has occurred in the last few years. The integration of DHFN supervision and supply functions into the ministry's decentralized system has created many problems. MSPP must now seek an effective management system to increase the contraceptive prevalence rate by meeting the large and growing unmet need. Some combination of vertical and horizontal service delivery may be essential. Full integration of family planning action into regional management may be possible only after programs of staff training. MSPP will need to assure that emphasis on maternal and child health is not diminished when it is combined with other health actions at the regional level. Population programs, as well as other programs of preventive health care, need continued nurturing and strong support from the central management of MSPP and technical backstopping from DHFN. 33. A thoroughgoing population plan would include population projections at least 30 years into the future, along with analysis of the implications for future income growth, agricultural development, urbanization, the environment and health status, of alternative population growth rates. The 1981-1986 plan provides no systematic link between program actions, investments in population-growth reduction and intended outcomes with respect to demographic variables. Such an exercise would complement and reinforce actions at the operational level by MSPP. Health Issues and Options 34. Within the health sector, government policy gives priority to primary health care. It &ims to strengthen rural health services and to decentralize the management and provision of health services. These goals are acknowledged to require an upgrading of MSPP management, logistics, information, training and supervision at all levels. There is very inadequate coverage of the population in need. Only 50 percent of women eligible for prenatal services receive them. The number of vaccinations given confers protection against diphtheria, pertussis and tetanus to but 5 percent of the under-fives. Productivity and utilization of facilities is very low: dispensaries in one district handled an average of only five clients per day in 1979. There is room for considerable improvement in the productivity of both health workers and health facilities.  -9- 35. Government policy in favor of primary health care is not reflected in its spending. Curative hospital services may absorb as much as eighty percent of the ministry budget; too small a share is devoted to primary care, particularly for the rural poor. Given resource constraints, one means to improve primary health care is to save money now spent on curative care. Thus there is an urgent need to make more efficient use of existing hospital resources. One option is to increase bed occupancy ratios from a current low level of 36.5 percent. This can be accomplished by concentrating limited personnel resources in fewer facilities. To increase efficiency there needs to be a more intensive use of dispensaries and health centers. The devolution of some tertiary care to private providers, and some forms of private or social insurance to finance health care, should be considered. 36. MSPP has made progress in restructuring its personnel and management. A remaining need is to assign a higher proportion of MSPP staff to the delivery of health services. Recent progress made by MSPP in analyzing how resources are currently being allocated (in terms of personnel distribution, salaries, budget, logistics and supply, and transport) and in improving statistics on health status, should be continued and consolidated, in order to increase productivity at the central ministry leve'l and in the newly organized regional and district health offices. Nutrition Issues and Options 37. The fundamental constraint to improving nutrition status is the shortage of food and the pervasiveness of poverty which blocks poor Haitians' access to the limited food available. Families do not waste food: a long-term solution to Haiti's problem of undernourishment depends on income and productivity growth. Food aid has in the past posed serious management demands in Haiti, and the objectives of that aid have not always been met. 38. Given current government priorities, as reflected in the pattern of expenditures, it seems unlikely that a major effort can be made to improve nutritional status. Feeding programs, food subsidies, and price policies aimed at helping the poor get enough to eat are beyond the range of possibility at this time. Nonetheless it is important to recognize the seriousness of the malnutrition problem. Long-term development will be impossible if children are wasted and stunted, thus entering school age unable to learn. More effective government response to nutritional needs could be achieved with better coordination between ministries which now share responsibility for service delivery and nutrition planning. 39. Immunization, growth monitoring, oral rehydration, and promotion of breastfeeding are central components of the primary health care system in the pilot programs developed so far in Haiti. These offer some hope of ameliorating nutritional problems and represent an advance over earlier  -10- programs that were too costly per child served. These programs require further testing and evaluation. If found to be financially feasible with respect to the recurrent costs which they generate for MSPP, they should be expanded. Such programs can then help compensate for the very low level of financial support which has in the past been devoted to nutritional needs. Malaria workers currently distribute chloroquine only, but they could be trained te distribute packets of oral rehydration salts and family planning materials. This change would allow greatly expanded coverage of both the diarrheal diseases control activities and family planning. The volunteers no longer collect blood samples on slides to monitor malaria, so the 1984 USAID evaluation concluded that these new activities would not involve more time spent by the volunteers. Building on the SNEM volunteer system could help spread low cost primazy health care to rural areas. Intersectoral Issues Sectoral Balance 40. A major sector policy choice is the balance to be struck between program efforts in population, health, and nutrition. MSPP budgets and staff resources are used predominantly for health services. It may be possible to tilt resources more in the direction of population and nutrition programs and at the same time address basic health care needs more effectively. Sector Financiinx 41. The issue of how to finance population, health, and nutrition programs is fundamental to the effective management of these sectors. The operating and development budgets of the Gover nent of Haiti are often analyzed separately. In the case of MSPP, this approach is unsatisfactory for two reasons. First, expenditures for wages, salaries and materials by DHFN, SNEM and other projects are counted as part of the development budget even though much of these costs should be part of the operating budget. To refer to such expenditures as development or investment understates the financial costs of maintaining day-to-day services in these sectors. Second, today's development-budget projects create the need for tomorrow's recurrent costs in the operating budget as donors seek to transfer th2 burden of paying for project activities onto the operating budget of the Government of Haiti. 42. Currently planned development expenditures will require very large operating expenditures in the future. These amounts may exceed the resources which the Government of Haiti can devote to this sector. The inability to finance an adequate level of operating expenditures is currently a serious cause for concern. What money there is in the operating budget goes almost entirely for wages and salaries (87 percent in FY84), thus limiting the complementary services, such as drugs and medical tests, and essential maintenance. Projections made in 1983  -11- (Table 4.1) suggested that public expenditures would grow significantly in the 1980s: In 1983 by 22 percent; in 1984, by 15 percent; in 1985 and 1986, by 10 percent. The rapid increases arise because projects in the development budget require increased expenditures in the operating budget as the projects are brought into normal operations. These include such valuable projects as rural health delivery, malaria control, health-center maintenance, and maternal and child care, all of which merit support within normal ministry operations. 43. International donors are reluctant to finance recurrent costs. When grant funds provided by bilateral donors are applied to recurrent expenditures, there are strenuous efforts made to guarantee that the Government of Haiti will be prepared to pay staff when the grant is concluded. Thus even grants eventually require that program expenditures be paid from government tax revenues. The share of taxes spent on these sectors is already high; therefore, it may not be feasible for spending in this sector to rise as fast as is projected. Options to be studied include greater efficiency in service delivery, some means to induce recipients of service to pay some part of their cost, and the shift of some services to the private sector so that th1ey would not constitute an excessive burden on limited tax revenues. Personnel Planning 44. The internal efficiency of service delivery in the population, health, and nutrition sectors is far lower than could be obtained. Before any consideration can be given to augmenting sector resources, further improvements in efficiency are both possible and essential. This will entail changes in NSPP personnel management and structure. Although there are over 10,000 MSPP checks issued each pay period, there are important, unmet needs for technical staff outside the capital. Almost half the ministry staff are administrative or other, and no mechanism exists for paying the salaries of health agents, the base of the primary health care system, when external funds are not available. Rural health services can be delivered effectively and at lower cost by volunteers, auxiliaries, and nurses than by trained physicians who are needed only for referrals at higher levels of service. One means to assure that skill levels are consistent with rural program needs is to complement the planned administrative decentralization with a decentralization of employment. Such a move would be consistent with the general Government effort to move activities out of the capital. A review of staffing needs in MSPP in light of priority attention to primary health care is essential. The review should also consider the social service program in order to make better use of the one-year service required of medical school graduates.  -12- Donor Coordination 45. More effective donor coordination by the Government of Haiti could help to increase the efficiency of resources devoted to these sectors. It could also lead to the mobilization of additional resources. Many of the agencies in the donor conmmunity favor of augmenting assistance to Haiti in the population, health, and nutrition sectors. Greater assistance ought to be contemplated if the government can effectively address the difficult issues identified in this report. Concludinu Note 46. This brief overview offers only an introduction to the population, health, and nutrition sectors in Haiti. More analysis of such topics as nutritional interventions, equity of service delivery, efficacy of vertical versus horizontal sytems of management, and the effectiveness of public and private organizations in this sector is needed. Systems of drug supplies, employee compensation, and productivity are all topics that would require more intensive study in the future.  -13- LIST OF TABLES AND FIGURES Page No. 1.1 - Summary of Population Statistics from Several Sources . . . 17 1.2 - Percentage Distribution of Women Ever in Union Aged 15-49 Years Reporting Knowledge of a Contraceptive Method, 1977 HFS . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 1.3 - Infant Mortality Rates (per 1000) for Port-au-Prince, Rural Areas in Haiti by Five Year Cohorts of Hales and Females for the Period 1956-1976, 1977 BFS . . . . . . . . . . . . . . 19 1.4 - The Components of Population Growth Rate in Haiti, 1970-2000 . . . . . . . . . . . . . . . . . . . . . . . . . . 20 1.5 - Causes of Death, All Ages . . . . . . . . . . . . . . . . . . 21 1.6 - Cause of Death, by Age, H6pital Albert Schweitzer, 1980 . . . 22 1.7 - Haiti: Prevalence of Undernutrition by Region, 1978 . .23 1.8 - Comparative Indicators of Population, Health and Nutrition Status, Haiti and Selected Countries . . . . . . . . . . . . . 24 3.1 - Distribution of Health Facilities and MCH/FP Clinical Outlets by Geographic Region, 1980 . . . . . . . . . . . . . . 29 3.2 - Expenditures on DSPP Health Services at District Level, FY78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 3.3 - Health Personnel in Haiti in All Sectors . . . . . . . . . . . 31 3.4 - Some Indicators and Comparators for Health Personnel and Sector Productivity, 1981 . . . . . . . . . . . . . . . . . . 32 3.5 - Haiti: Salaries of Civil Servants by Administration, 1978 . . 33 3.6 - Division of Family Hygiene Staff - Central office and Field June l978 . . . . . . . . . . . . . . . . . . . . . . . 34 3.7 - Average Daily Dispensary Utilization by Province - 1979 . . . 35 3.8 - Distribution of Visits Among Regions/District, 1979 .36 3.9 - Percent Distribution of Patient Contacts by Type of Health Facility - 1979 . . . . . . . . . . . . . . . . . . . . . . . 37  -14- Page No. 3.10 - Percent Distribution of Patient Contacts by Category of Contact, 1979 . . . . . . . . . . . . . . . . . . . . . . . . 38 4.1 - Haiti: Population, Health and Nutrition Budgets for Operating and Development Expenditures, FY77-'Y86 . . . . . . 43 4.2 - Projected DSPP Budget de Fonctionnement . . . . . . . . . . . 44 4.3 - DSPP Operating Budget for FY81 . . . . . . . . . . . . . . . 45 4.4 - DSLP Development Budget for FY81 . . . . . . . . . . . . 46 4.5 - Global Budget for the Realth Sector for 1981-1986 . . . . . . 47 4.6 - Haiti: Donors in Health, 1980 . . . . . . . . . . . . . . . 48 FIGURES 1.1 - Percent of Children 3 to 59 Months with Second or Third Degree Malnutrition . . . . . . . . . . . . . . . . . . . 25 3.1 - Organigramme - Departement de la sante publique et de la population (DPP) . . . . . . . . . . . . . . . . . . . . . . 39 3.2 - Distribution of Health Manpower in the Health Infrastructure Pyramid . . . . . . . . . . . . .. . . . . . . . . . 40 4.1 - DSPP Operating Budget, FY76 - FY77 . . . . . . . . . . . . . . 49  -15- POM=ON, HEALTH AND NUTRION STATUS  -9T-  -17- MTible 1.1: S[IY aF PC['ACN SMff=CS EL)I SEE9 L SOOE Total Crude Crue Tnfnt Nartiity Chid Pxpulatin Birth Dth Murtality Life Date Source (millions) Rate Rate Total Uroba Haral 1-4 years Hapectaucy 1971 IRS,Censu 4.3 36.5 16.0 147 - - 45 51 1970- Csaus and 1975 latirxoud Surveys 16.0 150 - - 27 1975- Projet ntr 1976 at Petit-Goave (rural) - - 107 18 52-3 1977 Haiti Fertility Survey 5.0 37 14.5 124 197 103 47.5 I1978 National Nutrition Survey - 147 119 1982 Cmsus, UN Estiutes 5.1 36 17.0 124 - - 31 48 1971 1980 2000 Urban Powulatimn (percit) 20.4% 27.5% 36.8X Ppulation DenS3ty per sque kilbmer: Overall: 156 180 Arable 1ad: 490-504 626 Amual Qxxwth Rate: 1.9X to 2.2% Total Fertility Nate: 5.5 overall; 4.0 (Pbrt-au-Prince); 6.1 (rural areas) (1974-76) Age structure: 5: 15.4% (estiutes for 1980) er 15: 405 Anmal OtMigrgtio At least 20,000 (0.); possibly ue than 40,000 Literacy: l0 to 20%  -18- Table 1.2: PERCENTAGE DISTRIBUTION OF WOMEN EVER IN UNION AGED 15-49 YEARS REPORTING KNOWLEDGE OF A CONTRACEPTIVE METHOD Percent reporting knowledge of Contraception METHODS 1977 IFS 1983 CPS 1. Pill 75.4 94.4 2. IUD 51.8 53.6 3. Female Scientific Methods 30.0 43.4 4. Condom 52.7 90.8 5. Male Sterilization 14.1 17.7 6. Female Sterilization 37.9 36.1 7. Abortion 55.8 72.6 8. Douche 31.7 - 9. Rhythm 55.9 20.2 10. Withdrawal 49.3 27.6 11. Abstention 41.8 15.1 12. Folkloric Methods 5.0 - 13. Injectables - 53.6 14. Natural Family Planning - 15.1 Total Efficient Methods (I - 6) 82.1 - Total All Methods (1 - 12) 85.2 Sc'Lrce: Enquete haitienne sur la fecondite, 1977. Table 4.2.2.; Bicknell, W.J., et al, 1984, p.70.  -19- Table 1.3: IlNFAiT MORTALITY RATES (PER 1000) FOR PORT-AU-PRINCE, RURAL AREAS IN HAII BY FIVE YEAR COHORT OF MALES- AlND FEMALES FOR THE PERIOD 1956-1976, 1977 C o h o r t s Area 1956-1960 1961-1965 1966-1970 1971-1975 Port-au-Prince 144 137 122 197 Ru-ral and Small Cities 124 142 143 103 Haiti 132 139 137 124 Source: Enque^te haitienne sur la fecondite 1977, Table 3.2.3.1  -20- TAble 1.4: lSE CQ 52R1 (F KIUUIt GROWM RA IN RATlT 1970-2000 (per 1000 paplatiE) Average Z Avmage Crue B2rth Crde !brt3lty Rate of Amhal GroWth Period Rate Rate rat Cbmath Rate 1970-1975 37.01 16.20 4.86 L5.95 1.595 1975-1980 36.78 14.48 4A2 17.88 1.788 198D-1985 35.58 13.00 3.61 18.97 1.897 1985-1990 33.51 11.52 329 18.70 1.870 1990-1995 30.89 10.18 2.19 18.52 1.852 1995-2000 28.29 9.09 2.01 17.10 l.no Source: Haitian Iustitte of Statistics, 1980.  -21- Table 1.5: CAUSES OF DEATH ALL AGES H8pital Albert Schweitzer, 1979-1980 /a DSPP, 1979 (n = 806 (n = 1430) Rank Diagnosis Percent Rank 1 Malnutrition 31Z 2 Diarrheas 15% 1 3 Pneumonia 12Z 2 4 Tuberculosis 10Z 4 5 Meningitis 7Z 10 6 Septicemia 6Z n.a. 7 Typhoid 4% 5 8 Tetanus 3Z 3 9 Prma-ture 3% n.a. 10 Malaria 2% 7 11 Congenial (newborn) 2Z n.a. 12 Respiratory Distress (newborn) 1Z n.a. 13 Post Partum 1% n.a. 14 Heasles 1Z 12 /a Multiple diagnoses are coded at BHpital Albert Schweitzer.  -22- Table 1.6: Cf1E CF =M, 1B AM Mpital Albert Scweitzer, 190 (a Infats Children Cbildrei Adlts Adults 0-1 m3utb 1-4 years 5-14 years 15-44 years 45+ n=247 (Z) n = 249 (Z) I u 104 O I u=116 (Z) I nl9D (Z) I I . I Diarrlm (22)1 !13Mutrition (71)1 N hJtitimn (35)1 TB (32)1 TB (19) Pum=ia (15)1 Diarbea (24)1 Typi id (12)1 ITypboid (10)1 C r (16) Septicemia (15)1 Pnemoia (19)1 Pamania (9) I Post partum (8) 1 Cirrhosis (13) Malzmtritim- (14)1t B (6) 1 TB (9) I alaria (6) 1C M (11) Manimitis (13)] }mengitis (5) 1 aaria (7) I *nits (3) 1 Coestive p e ture (9) 1 Typboid (3) 1 Diarrbea (6) 1 1 HEbat Tetarqis (6) 1 liesles (2) I I I Failure (9) Co%enial (6) 1 Septicemia (2) 1 I I !ningitis (6) Respiratory ITetau Te l)a I Distress (4)1 1 I I Pertussis (3) 1 I TB (2)1 1 I I La Mltiple diaposes are recorded at apit;al Albert Scimeitrar.  -23- Table 1.7: EHAM: PRElECE CF I)E RN IfhIf I BY E=Qq 1978 Deg de inutm.ritiml 3e 2e ler Noxmal B ic sggecgradque 60,0% 60,0-74,9 75,0-89,9 90,0+ Total Nord-ouest 3,0% 22,8% 48,M 25,4% 100,0% ( 891) NDrd 5,7% 28.5Z 46;!Z 19,67% 100,0% ( 892) Arti-buite 2.5% 28,3X 45,4% 23,7% 100,0% C 889) Ouest 2,7Z 23,4% 47,2% 26,& 100,0% ( 895) Sud 3,6Z 25,9Z 46,0% 24,5% 100,0% ( 893) F4mntila R Ptstif rural 3,5% 26,0Z 46,4Z 24,1% 100,0% (4A60) Port-mt-Prince 1. 13,1% 43,& 41,7% 100,0% ( 893) Fb1tilln M=atif lnatiXml 3,2% 24,1% 46,0Z 26,8Z 100,0% (5353) Qrwe sp6cial - 8,% 15,1Z 84,4Z 100,0% C 730) Souxce: .>quke natioiale sur 1"E= mutritim1 - Haiti 1978 -esm de NRtr.t ic - DSPPIA?JCDC  -24- Table 1.8: KWAT1VE WN)ICATO)S CIF NFVATIMI, FAIE IIIID EI~M SrAi - nArn AN C 9Ms ~Dniicen Naiti Republic Jamica Halatui 1. Goss Naticmal Thi (US$) per capita, 1983 32D 1,380 1,300 210 2. ptxatim. 1982 (tbousands) 5,201 5,744 2,246 6,452 3. Percentage Urban. 1982 26 53 48 10 Fertility 4. Crmde Birth Rate, 1982 32 34 27 56 5. Total. Fertiaity Rate, 1982 4.6 4.2 3.4 7.8 6, Z wmnusin Ct; I"e, 19al 5 42 55 - 3DtaitV 7. CreDeathREite, 1982 13 8 6 23 8. TIfaut Hortality Rate, 1982 (agedim*del) 110 65 10 137 9. Life epctaxy at birth,1982 54 62 13 44 -elth and Other Services 10. Umet n for lw/high Z 13/30 12121 21/25 - U1. Perscos per physician (1980) 8,20 2,320 2,830 40,950 12. brolbxt rate, prim", 1982 69 109 99 *2 13. hrolbwit rate, secoilaxy, 1981 13 41 58 4 Sources: World D3vent Beport 1984F and Word Bamk Ais 1985  -25- Figure 1.1: PERCENT OF CHILDREN 3 TO 59 MONTHS WITH SECOND OR THIED DEGREE MAILUTRITION 45 I Projet Intfgr 1975-1976 la co 40 1. *4, '4 I > 351 p' National c |,- _ DNutrition Survey /c o 30I - - Projet Inttrgr 30 1~ .. *' ' _ ~<$> *; i; _s_4t_ :s 1977-1978 lb .c I , - . o251 4 I ~20 3 ' w,I ,~~~~~~~~~~~~~~~I If; A 10 Y; 0 10 54 ~15 'dll 3 5 12 24 36 38 60 Age in Months Sources: /La Division dCRygie'ne familiale (1979). Pr&valence de la nalnutrition ... au debut de 1'etude, p. 114. /b Division dCRygiene failiale (1979). Pre'valence de la malnutrition ...a la fin de 'etude, p. 115 /c Baureau of Nutrition (1979). Table 7, Pe-rcentage distribution of preschool childreu by Gomez classes and age: Haiti 1978.  -26- 2a -10"; I evo;z- 'g7 /!w)Io /'  -27- SECTOR PERFORMACE  \\ i i  -29- T3b1e 3.1: DiS l IF MATAI3 /AUTJI ja AM 1ifP MMI=AL OFEfl /b Er (2MAFC L(N, 198D 1198 /a 1 D i I h Citers Bospita sL vith BEdsI I I Facilities District/ EFstimted only Offerag RogiG1 Pqulaticn I D9P ixced Privatel DMP |mxd I MP Priate [Total m I EPIE NaLioa lTotal 5,500,000 146 34 115 41 23 25 19 403 83 119 South egimo 1,120,000 39 17 17 21 2 5 1 93 7 39 NIrth egion 755,000 28 7 23 7 4 3 1 73 22 33 Pbrt-de-Paix 305,000 19 4 14 1 1 2 1 42 13 7 St. Hrc 400,000 6 - 9 - - 6 2 23 13 4 Qmasives 305,000 12 1 4 - 1 1 1 20 2 3 Rincxe 275,000 12 - 7 2 - 1 - 22 3 3 Belladere 290,000 3 - 2 - 1 1 - 7 - 5 Jaemel 290,000 19 - 2 - - 1 - 22 2 2 Petit-Goave 325,000 6 - 4 2 2 1 - 15 2 5 West 390,000 IC IC IC IC Ic IC /c /c 4 10 MetzoArma 985,000 11 c 5 33 8 12 4 13 86 11 9 Source: Searzaul Report "ACtiV2tes Of l(/P" Evalation and Reerch Section, IEF, DPs (October 1980. La Is&Th estimate ;b Evaluaticn and Reseerch Sectiom, ElF, DSPP 1981 Ic West and Itrn cobined  -30- Table 3.2: EPEDflmn (N Dcm Y HEATR V1C AT DSICT IEVEL, FYW8' District MY78 Eqmpiditures - in Il$ Per Capita - in Us$ Belladere $192,880 0.90 Cap BLitien 394,520 0.38 Cayes 385,540 0.62 Gaives 164,250 0.42 RHinbe 159,100 0.10 Ja_el 236,780 0.55 Jeremie 179,740 0.50 Petit-Goave 294,380 0.50 Port-au-Prince 2,201,060 3.36 Port-de-Paix 179,740 0.66 St. Irc 262,840 0.62 see $0.92 * ludes costs of aminirstratim, training, cetral DSP Staff, the SNEM and the IUF. Source: Developed frc BLx%get de Fc 0meent, Defay Report, and Facility Survey of the Statistics Sectim, ad AMD project mterials.  -31- Table 3.3: DISiRJJ1UIil Ci UFAT PEB9Sat f CT AM 1E 5 IN 1982 I NimD I IRA15S I OET I SD I 7ML I I _I I I Persiie I Fist. Necessi Exist. Necessi Exist. Recess Exist. Necs Eit. Necess. Nedecm 51 33 71 91 479 54 84 655 208 Dentiste 9 4 17 24 42 12 14 so 42 Tnfimier 68 25 64 94 295 71 91 498 210 kAudliiare 228 40 236 336 437 392 405 1,293 781 Tech. Lab. 34 15 19 30 89 13 19 155 64 Off. Sanit. 37 21 57 70 127 40 52 261 143 Statistdcim 11 4 1 6 40 4 4 56 14 Agent de Snte 130 40 103 203 231 164 550 628 793 Ies Autres 641 30 581 1,458 393 633 3,273 663 Total 1,209 212 1,149 854 3,198 0 1,343 1,852 6,899 2,918 Peed. 2 2 1 5 6 0 0 3 9 10 a3ir. 4 2 3 5 4 0 2 4 13 11 med. Int. 4 2 2 5 6 1 2 3 14 11 abgya. 7 1 2 5 4 1 3 4 16 U nrl 1 3 2 5 3 2 2 3 8 11 OArtLx3pe. 1 2 5 0 2 2 2 3 II 2Auestbes. 1 3 1 5 0 2 3 5 5 15 Total 20 15 U 35 23 6 14 24 68 80 Smurce: finistire de la S9=t6 pubWique et de la populatimn, "Evazuaticm des Prormmoes de sante," p. 30.  -32- Table 3.4: SCQE MHR UEIA3 PERSIEl AM SE FnflV-ff, 1981 lTkicatr or aGna r 1981 Hw-th sector labor force 10,000 /a TAl public setor labor force 29,000 Total Eaitian labor force (tbousands) 2,400 Gross Dstic P r c, $ nilim $1,49 Total public sector e nitures cur and developz0t bu%;ets, $ milliI $340 P-ublic sector bealth ezpeoditures, art and deelopnet bu%ets, $ millins $40 Avege GP per mer, dollars per $624 A-erW gomt wr I - ezpsiture per goveromwt ker, dollars per m $11,724 - bealth exuxitmes per goverzu.nt health woker, dollars per 4,000 sa N.ier of payroll cecks issued, 10,000, eceed *muer of employees.  -33- Table 3.5: AI, SAlARSm C CEVI 5WU E T, 1978. Meges & Salaries Numb~er of Average Salary Ak4iinistraui 0Os of Gt.ides lnployees in Girdes FOucation 28,929 6,624 /a 4,367 elth 28,242 5,518 5,118 Fcondic Services 39,864 5,181 7,694 Ces1 Pzblic Service 40,576 3,241 12,52) Cca.mity and Social Services 4,213 695 6,062 Witht ParetfDlio 392 10 39,18D Total 142,218 21,269 6,687 La Estim baued c budget; figure give by Miistry is 8,100 aox my sbx. plamed ina in persomel 'bich, aX the otber hud, aSppreat1y is not yet reflected in the budgeted salaries. Source: I= Report No. 2165-HL, Curret econc position aDd prospecu of Haiti, Volme II, Table 5.6, W