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International Society for Equity in Health ISEq. H 5 th International Conference, June 9 International Society for Equity in Health ISEq. H 5 th International Conference, June 9 – 11, 2009 SPH to mother, newborn and child populations: the case of Haiti Cecilia Acuña, Program Manager Extension of Social Protection in Health Systems based on Primary Health Care for Social Protection, PAHO/WHO Cristian Morales, Advisor on Health Systems and Services PAHO-WHO/Haiti Carlos Gril, Advisor on Maternal and Reproductive Health, PAHO-WHO/Haiti

CONTEXT • In 2007 the outcomes in maternal mortality in Haiti proved disastrous. MM CONTEXT • In 2007 the outcomes in maternal mortality in Haiti proved disastrous. MM increased from 457 x 100. 000 to 630 x 100. 000 in 10 years, in spite of a strong financial investment in programs aimed to reduce it • To tackle this problem, the Ministry of Health-MSPP decided to grant free of charge health services for pregnant women • This decision is the first step towards the construction of a Social Health Protection Scheme-SHPS in Haiti and it signals a shift in the orientation of the MSPP policies regarding mother and child health care financing

CONTEXT • The decision is supported by a Decree that allows free of charge CONTEXT • The decision is supported by a Decree that allows free of charge emergency obstetric services. The decree hadn’t being applied before due to the lack of resources but most of all because of a lack of political will • The decision is also a response to an intense lobby made by PAHO/WHO through a combination of technical arguments related to specific issues in maternal health and to the problems of health system (lack of access to health care, generalized practice of cost recovery, lack of a solidarity-based insurance mechanism) • It takes advantage of the financial resources available as a result of the humanitarian call for help made in 2006 which resulted in the project SOG (free of charge obstetric care for pregnant women)

CONTEXT • PAHO-WHO supported the decision making process that led to the establishment of CONTEXT • PAHO-WHO supported the decision making process that led to the establishment of the policy based on free of charge health services for pregnant women – In Haiti, the perception that free of charge health care was culturally harmful -i. e. could lead to both, a low regard of the services provided on the side of users and low quality of health services delivered on the provision side- was highly prevalent among Ministry of Health authorities and some international cooperation agencies • The events and decisions that contributed to the establishment of the free of charge policy follows

A Haitian Mo. H delegation along with PAHO FCH+ HSS country advisors participate in A Haitian Mo. H delegation along with PAHO FCH+ HSS country advisors participate in the Regional Forum “Social Protection in Health for women, newborns and child population in LAC: lessons learned that signal the way forward” held on November 08 -10 2006 -MM statistic data are published -Health Dept. Directors- DDs along with PAHO FCH+HSS advisors participate in the training Course “SPH challenges for MCH population: equity, access and health outcomes” organized by HSS/SPH-CIESS in Mexico on 2007 -The course provided an opportunity for the DDs to learn, discuss and incorporate SPH concepts and to start visualizing it as a tool useful in their reality. - Back in Haiti, the DDs told the Minister of Health of their support to the free of charge services delivery through the incorporation of SOG in their POAs Nov’ 06 Oct’ 05 Decree on free of charge obstetric emergencie s (Transition Govnmt) Mar’ 07 Dic’ 06 ACDI approves the SOG Project in the context of the humanitarian call A Seminar is jointly organized by FCH/HSS Haiti about lessons learned post-Bamako, free of charge services and the SOG project. Technical and financial cooperation agencies working in Haiti are invited -In Dec 2007 the Govnmt. launches a Forum to realign the health sector reform process, with the development of the SPH scheme as its axis -More than 270 people participate in the Forum -among them the Ministers of Health, and Parliament liaison, members of Parliament including the president of the Health Commission and three other Ministers (Social Planning, Social Affairs, Women condition), NGOs and International cooperation agencies Jul’ 07 May’ 07 MSPP asks PAHO-WHO’s support to set up a space to discuss and exchange experiences around the SPH concept, options adopted by the LAC countries and perspectives to build a SPH scheme in Haiti Dic’ 07 Sept’ 07 HSS, FCH/CLAP-MRH and PWRHAI organize a workshop in Port Au Prince on Sept 2007. Objective: support the MSPP on positioning inside and outside health sector the development of a SPH scheme as a State policy. At the end of the seminar, the MSPP publicly announces its will to start building a SPH scheme ensuring free of charge services for pregnant women as starting point En’ 08 Haiti’s Prime Minister launches the free of charge obstetric care project (SOG) as the SPH forerunner in Haiti

PRELIMINARY RESULTS TABLE 1. Type and Availability of Information. Source of Information availability Entity PRELIMINARY RESULTS TABLE 1. Type and Availability of Information. Source of Information availability Entity responsible to produce data Progress on implementation Key players at central, departmental and local level. 01/28/2008 PAHO/WHO Demand supply response Project Database. Available July 2008 (only preliminary information available) PAHO/WHO Technical Quality of services Project Database: technical quality indicators. Available July 2008 (only preliminary information available) PAHO/WHO Perceived quality of service (satisfaction) Longitudinal survey on beneficiaries’ satisfaction. As of July 2008 to April 2009 External firm Structural aspects of quality of services Periodic and regular field visits at providing institutions. As of August 2008 and during all the life of the Project. Mo. H Health Services Organization Department Clinical and epidemiological profile and the obstetric and perinatal results. SIP & project database Available July 2008 (only preliminary information available) PAHO/WHO Type of Information

PRELIMINARY RESULTS¹ Table 2. Structural and Operational Factors Determining Project Performance Structural Factors Performance PRELIMINARY RESULTS¹ Table 2. Structural and Operational Factors Determining Project Performance Structural Factors Performance Availabi lity of HHRR at manage rial level Presence of volunteer staff (Cuban cooperatio n brigade /mission members) Operational Factors the District Directio n of the Hospital’s manageme nt Ownersh ip by the medical staff Transpare ncy / corruption * Capacity to mobilize addition al resource s Leaders hip of Leadership PDH 1 +++ +++ +++ n/d +++ PDH 2 - -/+ + - - -/+ +++ +++ - +++ n/d ++ PH ¹As of July 2008 *Informal mechanisms and frauds which, in the costs recovering system, generated financial profits for some staff groups.

PRELIMINARY RESULTS Table 3. Increase of Access to Obstetric Services at Selected Institutions as PRELIMINARY RESULTS Table 3. Increase of Access to Obstetric Services at Selected Institutions as of July 2008 Health Institution Health Department Baseline 2007. Deliveries per month 40% increase from baseline. Project Target Institutional deliveries during first month Dame Marie Hospital (AEDMA) Grande Anse 5 7 13 160% Ste-Thérèse DH in Miragoane Nippes 39 56 96 146% La Paix University Hospital West – Metropo litan Area 103 145 191 85% DH in Fort Liberté Northeast 38 53 123 224% HCR St-Marc Artibonite 87 122 196 125% St-Boniface Hospital in Fonds des Blancs South 33 46 50 52% DH St-Therese in Hinche Centre 45 63 113 151% Average Increase compared to baseline 135%

Evolution of the Number of Deliveries in Two Selected Facilities Evolution of the Number of Deliveries in Two Selected Facilities

CONCLUSIONS • Preliminary data for some of the participating institutions show that the elimination CONCLUSIONS • Preliminary data for some of the participating institutions show that the elimination of the financial barrier produced a significant increase in the demand for obstetric care. • This increase of institutional care for pregnant women allows not only to provide for a basic package of service under a performance-based contract, but also ensures a platform from which different actions with potential impact on maternal health may be added as long as additional funds become available. • One clear example is UNFPA’s declared intention to add to the project a post obstetric-event contraception intervention.

CONCLUSIONS • The increases in the first months of operation of the project lead CONCLUSIONS • The increases in the first months of operation of the project lead us to anticipate in the near future two bottlenecks that may put at risk the continuity of this innovative experience: – The first one has to do with the need to increase funds mobilization to ensure the continuation of the project. – The second relates to the inevitable need to increase investments in institutional development and human resources, i. e. to strengthen the supply side accordingly with the increase of the demand for health care.

CONCLUSIONS • The transformation of the pilot experience into a public policy in the CONCLUSIONS • The transformation of the pilot experience into a public policy in the future, incorporating a budget line to finance a first SPH scheme, will call for a firm political commitment and consistent leadership capacity from the new authorities to progress towards two converging strategies: – MSPP’s access to a portion of the funds from the External Debt Reduction Program. – The alignment of the different international donors, agencies and financial institutions with a national program that will collect the different available funds (following the example of the Bolivian Mother and Child Insurance) towards the construction of a progressive SPH scheme along with a policy for strengthening their provision of health care.

Challenges • Establish a follow up agenda with short and mid term actions to Challenges • Establish a follow up agenda with short and mid term actions to support the development of a SPH scheme as a State policy based on two axis: – The free of charge care project for pregnant women and newborns – The political construction of the SPH concept as a State policy in the country • Incorporate the achievements of the process to the National Forum for the realignment of the Health Sector Reform in Haiti.

Strategic importance of SPH policies in Haiti • Democracy building, social cohesion and construction Strategic importance of SPH policies in Haiti • Democracy building, social cohesion and construction of agreements around the State • Health System reform and contribution to the economic development and poverty reduction • Compliance with the MDGs • Sub regional migratory agreements with Dominican Republic

The political economy of SPH in Haiti • The successful implementation of SPH strategies The political economy of SPH in Haiti • The successful implementation of SPH strategies requires conveying the interests of the many players and setting up spaces where they can negotiate and achieve agreements • Actors that gather or represent the interests of the community have a central role to play • Given the political instability of the country, it is very important that citizens develop ownership towards the intervention so they can defend it

THE SHORT TERM SITUATION • High political instability remains • However, the SOG keeps THE SHORT TERM SITUATION • High political instability remains • However, the SOG keeps operating • Preliminary results are encouraging WINDOW OF OPPORTUNITY TO FORMULATE A COHERENT SPH AGENDA