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—from Epidemiological Bulletin, Vol. 24 No. 1, March 2003


Country Profiles

Haiti

General situation and trends
Haiti occupies the western third of Hispaniola, the second largest island in the Caribbean. Its nine departments occupy a land area of 27,700 km2. The first country to declare its independence in the Americas, Haiti’s recent past has been marked by political and social violence. After several years of political conflicts, elections were held in 2000 for municipal officials, new deputies, senators, and finally, the presidency.

The 1990s saw a worsening of poverty for the Haitian population. In 1999-2000, the growth in the GDP was 1.2%, a decrease compared to the previous period that is mainly explained by the decline in the contribution of the agricultural sector (-1.3%). Inflation was estimated at 15% in 1999-2000 and during the same period the price of food increased 10.4%. A survey conducted in 1999-2000 found that 67% of the population was living in poverty, that 31.4% of the households had more than seven members and that 46% of families had only one room to sleep in.

Figure 1: Gross Domestic Product, annual growth (%), Haiti, 1991-2000

The official languages are Haitian Creole and French, the latter being used to a large extent in the cities. The population in 2000, based on the census of 1982, was estimated at 7,958,964 for a density of 282 inhabitants per km2. The estimated annual population growth rate during 1995-2000 was 2.1%. Sixty-four percent of the people live in the countryside, 21% in the metropolitan area of Port-au-Prince, and 15% in other urban areas. Forty percent of the Haitian population is under 15 years old, and only 5% is over 65. The population dynamic has been characterized by a progressive urbanization, emigration to countries abroad and a shifting population toward the neighboring Dominican Republic.

Figure 2: Population structure, by age and sex, Haiti, 2000

A sizable percentage of professionals and qualified technicians contribute to the Haitian diaspora, especially the United States (Florida and New York), Canada and neighboring islands. The monthly remittances sent to families in Haiti account for 8.3% of household income. The crude birth rate was 33 per 1,000 population, and the general fertility rate was 4.4 children per woman. Life expectancy at birth was 54.4 years for the general population (52.8 for men, 56 for women).

Since 1997, the Ministry of Public Health and Population (MSPP) and PAHO have been promoting the certification of deaths. In 1999, a total of 7,997 death certificates were issued, believed to represent 10% of all deaths. Although almost half the certificates show ill-defined causes of death, the information gained allowed a mortality profile to be defined. Communicable diseases headed the list, representing 37.5% of deaths presenting a defined diagnosis. The second most important group was diseases of the circulatory system. External causes ranked third (4.3%) and neoplasms were in fourth place (2.7%). In terms of specific causes of death, AIDS ranked first, with 5.2% of the total deaths, followed by diarrhea and infectious gastroenteritis (5%) and cerebrovascular accidents (3.5%). Of the 10 leading causes of death in women, the first three coincide with the general pattern, but maternal causes come fourth, with 157 deaths.

Specific health problems
By population group
Children (0-4 years): Infant mortality increased from 73.8 per 1,000 live births in 1996 to 80.3 in 2000. The rise is associated with increased poverty, deficiencies in the health system, and the impact of the AIDS epidemic. Acute diarrheal disease is the number-one health problem in children. The leading causes of death in 1999 were intestinal infectious diseases (12.1%), infections of the perinatal period (10.2%), malnutrition (9.1%) and acute respiratory infections (6.9%).

Schoolchildren (5-9 years): An estimated 20% of the group under 15 years old are in a state of vulnerability, i.e. living in poverty, undernourished, with limited access to education, residing in foster homes where they do domestic work (a situation referred to as restavek), or else in the street. In the age group 5-14 years, infectious and parasitic diseases accounted for 24% of the registered deaths. External causes represented 10% of all causes of death.

Adolescents (10-14 and 15-19 years): According to death certificates for 1999, adolescents and youth accounted for 8% of the deaths in the country. HIV/AIDS was the leading cause of death in this age group (5.8% of all certified deaths). Among the 10 leading specific causes of death on this population group were assault and homicide, tuberculosis, typhoid, and causes related to maternity (35 maternal deaths in the age group 10-24 years in 1999). The fertility rate in girls aged 15-19 years was 80 per 1,000 in 2000. The prevalence of sexually transmitted infections in adolescent males 15-19 years old was 9.9%. In one survey, 18% of the females and 33% of males stated that they had used a condom in their last sexual encounter. Violence and sexual abuse are very frequent in this population group (70% of adolescent girls and women have been exposed to violence of some sort).

Adults (20-59 years): The fertility rate is in decline, estimated at 4.7 children per woman in 2000. Of all women with a regular partner in 2000, 22% were using a modern method of contraception and 5.8% a traditional method. AIDS is the leading cause of death for the population 15-49 years of age (21.6% of deaths with specifically defined diagnosis). Intestinal infections come second and maternal causes rank third. The maternal mortality rate in 2000 was 523 per 100,000 live births, a 15% increase relative to 1995. Maternal causes of death included problems related to arterial hypertension and eclampsia, as well as complications of labor. Seventy-eight percent of pregnant women had prenatal checkups with a health professional in 2000.

The Elderly (60 years and older): There is no definite social security policy for this population group, nor specific health programs for older adults despite efforts by the State. In 1999 the causes of death were mainly noncommunicable diseases. Diseases of the circulatory system accounted for 39% of the deaths with a valid diagnosis. Malignant neoplasms of the digestive organs, along with tuberculosis and HIV/AIDS, were among the 10 leading specific causes of death.

Family health: Constant displacement and migration abroad are causing the family structure to break down in urban and rural areas. There are no programs geared to family health.

Workers’ health: The informal sector (mainly women) and the agricultural sector make up 96% of the working class. No services are provided for this informal sector. Government workers have a poorly organized insurance system, while the health of employees in the private sector comes under the responsibility of the Office of Medical Insurance and Maternity. In 1999-2000, the indemnity for temporary incapacity or permanent disability was paid to 559 persons, 90% of them men.

The disabled: It was estimated in 1998 that 7% of the Haitian population had some form of disability, half of them occurring in children under 15 years of age. Blindness was the most frequent disability (1% of the population).

Border population: A socioeconomic survey conducted in communities of sugar cane workers in the Dominican Republic showed that 27.5% of the mothers stated that they were of Haitian or Dominican-Haitian origin. The survey found that 20% of children under 5 years with Haitian mothers were suffering from moderate or severe malnutrition.

By type of health problem
Natural disasters: Haiti is susceptible to hurricanes because of its geographic location. Because of the severe deforestation throughout the island, even normal rains can cause floods in urban areas. It is also at risk for earthquakes because of its location on eight tectonic faults. In September 1998, Hurricane Georges claimed 230 lives, caused damage or injury to 344,000 persons and battered 13,000 homes. In November 2000, torrential rains caused major damage in the Department of the North.

Vector-borne diseases: Plasmodium falciparum malaria is endemic, causing 59 deaths in 1999 (with 90% underregistration and data from only 4 departments) and a total of 973 cases reported to the MSPP. Epidemiological data are insufficient to estimate the magnitude of the dengue problem in Haiti, but in 2000, 59 clinical cases of dengue were reported. The Aedes aegypti vector is present throughout the country. Lymphatic filariasis is widespread in urban areas, especially in the Department of the North. In some cities of the North and of the Center, the rate of microfilaria carriers exceeds 30%.

Diseases preventable by immunization: As a result of the discontinuation of vaccination efforts during 1995-1999, an epidemic of measles occurred in the city of Gonaïves in March 2000 (990 confirmed cases, most of them in the area of Port-au-Prince, during that year). Despite immediate vaccination efforts, cases were confirmed in various municipalities. By the end of 2000, measles vaccination coverage had reached 75% in the country. Unsatisfactory vaccination coverage resulted in a case of acute flaccid paralysis reported in 2000 in a 2-year-old girl. Virologic studies identified a poliovirus derived from the Sabin type 1 vaccine. Seven more cases occurred in 2001, the last one in July. Vaccination coverage after the epidemic was 100%. Eight cases of diphtheria were reported in 1999, and 60 cases of neonatal tetanus in 2000. However, the true number of cases is thought to be greater.

Figure 3: Vaccination coverage among the populationunder 1 year of age, by vaccine, Haiti, 2000

Intestinal infectious diseases: Diarrhea and gastroenteritis are the second leading cause of death in the general population, especially in children. Typhoid accounted for 67 registered deaths in 1999, although it is not subject to surveillance.

Chronic communicable diseases: In 1999, the estimated prevalence of tuberculosis - the sixth most important cause of death in the country - was 114 per 100,000 population. The network of health services observing the WHO DOTS strategy is incipient. The AIDS epidemic has aggravated the tuberculosis situation. It can be said that leprosy is still endemic in Haiti, although its true prevalence is not known.

Acute respiratory infections: According to the 1999 death certificates, there were 209 deaths attributable to acute respiratory infections, 97 of them in children under 5 years of age.

Zoonoses: During 1995-2000 there were 22 reported cases of human rabies and 44 cases of laboratory-confirmed canine rabies, most of them in the Port-au-Prince metropolitan area. Prevention measures such as canine vaccination have been stepped up. Anthrax is endemic in the departments of the North, Southeast, and the Artibonite, but no data is available.

HIV/AIDS and sexually transmitted infections: HIV/AIDS infection affects 4.5% of the Haitian population. It is estimated that every year there are some 13,000 pregnant women who are HIV-positive, and that 30% of their children will be born with the infection. In 2000, a study showed prevalence rates in pregnant women of 5.6% for syphilis and 3.8% for hepatitis B. In 1999-2000, the screening of prospective blood donors showed that 1.4% were positive for HIV, 3.6% for hepatitis B, 0.1% for hepatitis C, and 0.8% for syphilis.

Nutritional and metabolic diseases: According to a survey, overall malnutrition in 1995 was 67.3%. Malnutrition ranks eighth among the causes of general mortality, 76% of cases being in children under 5. Prevalence of anemia is believed to be high. A 1997 study of household and maternal determinants of vitamin A and iron status showed severe stunting in 31% of the sample, and wasting in 4%. Ninety-two percent had vitamin A deficiency. Numerous foci of iodine deficiency have been found and cases of cretinism reported. In 2000, the prevalence of exclusive breast-feeding for 0-5 months was 49% and non-exclusive breast-feeding 99%.

Diseases of the circulatory system: Cerebrovascular diseases are the third leading specific cause of death; other cardiopathies are in fifth place and arterial hypertension in eleventh place. There are more registered deaths among females than males.

Malignant neoplasms: They correspond to 2.5% of registered deaths with a certified diagnosis. In 1999, there were 196 cases of malignant neoplasms (111 in females and 85 in males), the malignant tumors of the digestive tract heading the list (66 cases), followed by those of the male genital organs (33). This information is not conclusive because of sizable underregistration.

Accidents and violence: They contribute significantly to morbidity and mortality in Haiti, especially in the economically active population and among adolescents and youth. In 1999, there were 98 deaths due to transport accidents (12th place among all causes of mortality) and 70 deaths due to assault with a firearm (16th place).

Oral health: Surveys in small localities have found a 37% prevalence of caries in 12-year-olds in the city of Jérémie. It revealed that in 1996, 50% to 79% of the adults had at least one missing tooth and only 1% of the 17-59 years of age had teeth with fillings.

Emerging and re-emerging diseases: In 1999, there were 56 cases of meningococcal meningitis with a case-fatality rate ranging between 20 and 30%.

The response of the health system
National health policies and plans
In 1998, the MSPP published its national health policy, which calls for the strengthening of the Ministry’s steering role in the planning, execution and evaluation of health programs, while recognizing the difficulties it had to face with inadequate human and financial resources to serve a nation immersed in poverty and with great health needs. The Municipal Health Units (UCSs) are decentralized administrative units responsible for carrying out a series of health activities with the participation of the community. Although traditional medicine is recognized and widely practiced, it does not receive direct support from the health sector.

Health sector reform strategies and programs
The primary health care strategy serves as the basis for national health programs. Although not yet institutionalized in the health services, it is provided in the form of a minimum package of services that includes health care for children, adolescents and women; emergency medical and surgical care; communicable disease control; public health education; environmental health; water supply; and the supply of essential drugs. The second strategy is the reorganization of the health system, which includes the still incipient functional decentralization of the Ministry based on the UCSs.

The health System
It includes: a) the public sector (Ministry of Public Health and Population and Ministry of Social Affairs); b) the private for-profit sector (all health professionals in private practice); c) the mixed nonprofit sector (Ministry of Health personnel working in private institutions (NGOs) or religious organizations; d) the private nonprofit sector (NGOs, foundations, associations); and e) the traditional health system. A number of central bureaus execute the health programs (except AIDS and tuberculosis, directly under the Office of the Director General). There are also 10 directorates (one for each department and for the Nippes Coordination), under which come the UCSs. Due to the country’s political problems, there has been no recent progress in health legislation. All health system institutions are coordinated by the Ministry of Health, however it has been unable to assume its leadership role in the recent past, as the economic embargo directed resources toward the nonprofit sector. The health services reach 60% of the population. There are 371 health posts, 217 health centers and 49 hospitals. It is estimated that 40% of the population relies on traditional medicine, mostly in rural areas.

Organization of Health Regulatory Actions
The inadequate legal framework hampers the formulation of strategies and the execution of activities to guarantee minimum services. The nation’s laws governing the safety and efficacy of drugs were enacted in 1948 and 1955. The new law, drafted in 1997, has still not been approved because of political problems.

Environmental quality: As 71% of the energy consumed in the country comes from wood and charcoal, only 3% of the land area is covered by natural forests, causing soil erosion and clogging urban sewers with mud. In dwellings, coal smoke causes many respiratory problems, especially in children. Inadequate management of excreta and household refuse causes contamination of surface waters.

Organization of public health care services
Health Promotion services: Communication activities are integrated into various MSPP programs, which collaborate with the health media. The healthy municipalities initiative got underway at the end of 1998.

Disease prevention and Control Programs: High priority is given to AIDS and tuberculosis control, through networks with NGOs, public and private institutions. A program for feeding schoolchildren and the control of parasitoses was initiated in 2000.

Health analysis, epidemiological surveillance, public health laboratory systems: The health sector has no established health information system that would generate a culture of use and analysis of information. A strategic plan for the development of epidemiology was designed in November 2000, with 6 lines of action to remedy this deficiency.

Potable water and excreta disposal services: Access to water for human consumption is a major problem in Haiti. The Metropolitan Autonomous Station for Potable Water is the State enterprise responsible for the distribution of potable water. In 1999, the potable water supply system reached 47% of the population in the Port-au-Prince area, 46% in secondary cities, and 48% in rural areas. In 1999, coverage with excreta disposal systems was 44% in urban areas and 18% in rural areas. There is no control of hospital waste.

Food safety: The Ministry of Agriculture has a food control laboratory, but only for monitoring purposes. It is impossible to exercise any control over the sale of prepared food sold in the street.

Food aid programs: It is estimated that 159,000 tons of food aid was received by Haiti in 1994 (68% from the US) and programs are carried out mainly by NGOs.

Organization of Individual Health Services
Although mental health is not considered a national priority, there are two government institutions that provide mental health care in the Port-au-Prince area. The Haitian Red Cross has 6 transfusion centers in the department capitals and there are also centers in private institutions, although blood safety cannot be guaranteed in the latter.

Health supplies
There are three pharmaceutical laboratories that have been officially designated to produce drugs for national use and they cover 30 to 40% of the Haitian market. Drugs are dispensed at numerous sites (some unauthorized). The public sector has an essential drug program with a decentralized logistic system. Eighty percent of the country’s expenditure on drugs is made by the private sector. With the problems involved in regulating the sector, it is impossible to know the precise volume of pharmaceutical products available on the market.

Human resources
In 1998, there were 2.4 physicians per 10,000 population and in 1996 there was 1 nurse per 10,000 and 3.1 auxiliaries per 10,000. There are sizable differences by departments. Human resources are insufficient but lack of funds has prevented the MSPP from creating new positions and many professionals go into private practice or emigrate. In 1999, a bilateral cooperation agreement was signed with Cuba, under which 500 Cuban health professionals have been working in 62% of the municipalities, for 5 years until the return of 120 young Haitians now studying medicine in Cuba. There are public and private schools (of the four private schools of medicine, only one is recognized by the State). In 1998, there were nine recognized nursing schools. In 2000, a school for nurse-midwives opened. Oversight of trainingof health personnel and of professional practice is ineffective. Since 1998, a dozen public sector hospital administrators and directors are trained every year.

Health Research and Technology
The Epidemiology and Research Service under the MSPP is responsible for planning and carrying out research contributing to policies and programs in disease prevention and control. There are financial limitations and lack of trained personnel. Several other institutions conducting research are not approved or overseen by the MSPP.

Health sector expenditure and financing
Public funds spent on health represent only 0.8% to 1% of the GDP. Most of the MSPP’s allocation (US$ 57 million in 1999, unchanged since 1996) is spent on salaries. Execution of the investment budget, which depends largely on foreign aid, was 49% in 1999. Activities are thus slowed down or halted and morale is low. To remedy this, operational spending was decentralized in 1998 in all departments except the Department of the West.

External Technical Cooperation and Financing
Nine specialized UN agencies have offices in Haiti, six of them working in health. There is also cooperation with the IDB and the European Union and bilaterally with USAID, CIDA and the governments of France, the Netherlands and Japan. When Haiti joined CARICOM, regional integration was strengthened. However, there are still not many collaborative activities with the Dominican Republic except joint meetings and visits by technicians to both countries, as well as a project on prevention and control of rabies.



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Epidemiological Bulletin, Vol. 24 No. 1, March 2003


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