Community Health Financing as a Pathway to Universal Health Coverage: Synthes...
Dorce Final Draft PST 320
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Glorianne Dorcé
PST: 320:01
S. Sieck & B. Graham
December 11, 2015
The Western Hemisphere's Epidemic:
Analyzing Haiti's Future Providing HIV medicine to its People
Abstract
This paper is used to assist academic audience of policy analysts or policy makers on
evaluating the best alternative for a foreign country such as Haiti. Compared to HIV in Africa, it
is a much smaller problem in the Western Hemisphere. Nonetheless, Haiti has 120,000 people
living with HIV, making Haiti face an epidemic (Avert, 2011 and 2012, Caribbean HIV & Aids
statistics). Now, the main topic of the paper is to explain on how Haiti is facing an HIV epidemic
where their government is unable to provide medicine to the patients. Haiti being ranked as one
of the top 30 countries with the highest percentage of population living with HIV, one wonders
on why they are not getting better access towards medicine (CIA, 2014). The policies evaluated
in this case will depend on the influence they have on the percentage of HIV patients getting
treated, the cost-effectiveness and feasibility of implementing said policies.
Problem Definition
A good thing however is that HIV can be controlled by providing triple drug
antiretroviral therapy (ART), but the drug is very expensive (Deschamps, 2000). The problem in
Haiti at the moment is that HIV patients in Haiti are having trouble in accessing to medicine.
Firstly, the population is too poor to buy the ART on their own. Furthermore, the government is
lacking resources to afford the drugs, let alone distribute them, reason for this is that Haiti is
ranked 150th out of 175 countries in income (Edmonds, 2012). The government is also unable to
fund doctors whom may prescribe the medication to the patients. In fact, there is less than one
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doctor per eight-thousand people in Haiti (Ersegovina, 2015), which is twenty times less than
that of the United States (World Bank, 2011). Analysis has also been done by The World Health
Organization displaying the average population covered per primary health facility in 2008
(Figure 1). On the other hand, another factor contributing to Haiti’s problem is that they face
democratic reconstruction every few years, providing major questions on how
feasible implementing a policy through the state would be.
Figure 1: World Health organization data on 2008 estimated Average population covered per primary health
facility.
The government in Haiti needs to find a solution that will assist them in providing
accessibility to HIV medication for their citizens. The lack of resources and fluctuating
government however will make it difficult in finding a policy that would assist in addressing the
demanding needs of HIV patients. The solution is finding another method in getting the
medication distributed to the HIV population. This may be done by implementing policies that
assists institutions and pharmaceutical companies in providing sufficient amounts of medication
for HIV patients. If the Haitian government is still incapable of supplying medication to the HIV
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patients or even a substitute solution then the HIV epidemic will continue a few more
years.
Criteria
In order for the government to implement a policy that will assist in providing HIV
medicine to its people, there must be a few standards that assess how the alternatives may impact
the country. The criteria will be on: percentage of HIV patients getting treated, the cost-
effectiveness, and feasibility of policy being implemented. The percentage of patients receiving
treatment (“HIV treated”) will demonstrate on how effective the alternative policies have been in
providing treatment to the Haitian HIV population. “Cost-effectiveness”, so that the alternative is
favorable, the policy must have a high percentage of HIV patients receiving treatment at a lower
cost than the other alternatives. Lastly, feasibility of a policy being implemented (“Feasibility”)
predicts the possibility of policy being passed by examining the current political, and economic
environment of Haiti. Now, each criteria will have a weight designated, and based on the
weights of each criteria, the alternatives will be evaluated from being the least to most effective
in addressing the problem. Figure 2 displays the weights of each criteria and how the alternative
will be analyzed.
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Figure 2. HIV treated (.45) + Cost-effectiveness (0.275) + Feasibility (0.275) = Effectiveness of alternative.
1=least effective, 5= most effective.
Starting with “HIV treated”, increasing the percentage of HIV patients receiving
treatment will conclude that the policy is a successful alternative. The percentage of patients
receiving treatment will be based on patients who have access to antiretroviral therapy (ART).
This percentage will inform how successful the alternative is in providing ART in Haiti. This is
related to our current problem because the goal is to submit a policy that helps people access to
ART.
Additionally, Haiti being poor needs to have stricter control on their money because of
the economic environment they are in now. This makes it important to do a cost-effectiveness
analysis (CEA) can “identify ways to redirect resources to achieve more" for the same cost, such
as providing medicine to the people (Jamison DT, Breman JG, Measham AR, et al, 2006). The
cost-effectiveness will analyze the ratio between the amounts of HIV patients receiving treatment
over the cost of providing the treatment. Consequently, for the alternative to be favorable, the
policy must have a high amount of HIV patients receiving treatment at a lower cost than the
other alternatives.
An equally important independent criteria is known as political feasibility. The feasibility
of a policy is dependent on Haiti's current political environment, key factors being the
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country's economic and social standing. The economic and social standing of the government
will help whether or not the government would oppose, remain neutral or advocate for a certain
policy (Meltsner, 1979). Example of this is the government leaning towards a more cost-
effective policy if they are worried of the GDP of their country, or leaning towards an alternative
that has a stronger social impact if they are trying to appease a certain advocacy group.
Understanding the various relationships the government has with their environment and other
key members-clinics, foreign organizations, citizens of Haiti- will identify which trade-offs the
alternatives provide will become more favorable than the next.
Evidence and Alternatives
Alternative 1: Status Quo “Existing state of Affairs in Haiti”
At the moment there is no policy the government is specifically funding for HIV
medicine accessibility. Instead Haiti is dependent on foreign non-governmental organizations
(NGOs) to provide for the lack of resources available. Currently, an NGO called Population
Service International (PSI) created and is funding a program that provides education on sexual
health and distributes contraceptive goods in attempt to prevent unintended pregnancies (PSI,
2015). The program is called Preventing Mother-to-Child Transmission of HIV or PMTCT
program.
The PMTCT program also provides pregnant women free HIV testing, and if declared
positive they supply ongoing psychosocial counseling for the entire family of the pregnant
woman. Furthermore, to prevent an HIV positive mother from transmitting HIV to the child
through breastfeeding, the suggest variations of feeding their child through the educational
classes provided by PMTCT program. A common problem with providing alternative
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breastfeeding options is that the majority of the Haitian community believes that if a mother is
unable to breastfeed, than the mother is unfit or handicapped (Gupta, Whelen, and Allendorf,
2006, 25). Nevertheless, if the mother is able to face this stigmatization and follow the PMTCT
program, the PSI will try to provide a clinic that prescribes antiretroviral therapy near the
mother's village through the NGOs network (PSI, 2015).
Currently, PSI is providing all the funding for the program based on the current NGO
networks PSI is connected with. By 2011 around 77% or pregnant women living with HIV in
Haiti had access to services that PMTCT of HIV, which lead to a 25% decrease in the number of
children born with HIV (UNAID, 2012). Furthermore, the impact that the PMTCT program had
with their networking clinics has decreased new HIV by 54%, and AIDS-related deaths at a
steady decline of 47% from 2001-2011 (UNAID, 2012). Based on these results the Haitian
government has high remarks on the effectiveness of the PMTC program funded by PSI and
other foreign NGOs just like it. The cost-effectiveness of the program is even explained by the
Haitian President, Michel Martelly, in which “it costs only US $150 [ funded by NGOs] to
prevent a child being born with HIV, [while] it would cost hundreds of thousands of dollars to
treat a person living with the virus over the course of their lives" (UNAIDS, 2012).
Provided with these results the Haitian government may believe that there is not an issue
with Haiti's government not having funding for HIV medicine accessibility, when Haiti can just
rely on NGOs. Evidence for this is that, more than 75% of funding for Haiti’s HIV response
comes from external sources (UNAID 2012). However, if PSI and the rest of the NGOs for
some reason decided to leave Haiti, who would support the HIV patients in Haiti? Now, if the
government continues to neglect in providing services that may assist HIV patients, it is
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questionable on how stable it is being dependent NGOs always providing the services needed to
assist HIV patient’s access to medicine.
Alternative 2: Anti-discrimination Law
Another cause for patients being unable to access medication is the discrimination HIV
patients must face. An option that could be used to reduce discrimination is the government
passing an anti-discrimination law, like the one in Bolivia called Law 045 against Racism and
All Form of Discrimination or “Ley 045 Contra el Racismo y Toda Forma
de Discriminación". The law prohibits discrimination because of social status, sexual orientation,
gender, and race (Bolivia, 2010). This law is essential for Haiti’s socioeconomic imbalance, and
discriminatory views facing both genders with HIV and other such discrimination that may
hinder providing medication to the patients.
In rural Haiti, extreme discrimination occurs when someone is declared HIV positive and
can face ostracism, be blamed for the disease, and denied treatment (Pamela Surkan, 2010).
Example for this type of ostracism and blame for disease is seen in the homosexual community
of Haiti. Many Haitians have a strong faith in Christianity and Voodoo and practice informal
healing procedures (Kidder, 2003). Some believe that HIV can be cured by confessing their sins
to such practices and following faith healing practices (ERZEGOVINA, 2015). Furthermore,
homosexuality being viewed as a sin makes Haitians believe that those who are homosexual
deserve HIV since they are living in sin. This is powerful since an estimated 18% of Haitian men
who have sex with men are living with HIV (UNAID, 2012).
Another form of discrimination on HIV prevention that is highly prevalent in Haiti and
other underdeveloped countries is gender inequality. It appears that gender plays a significant
role on the individuals risk and vulnerability in the HIV/AIDs epidemic (Gupta, Whelen, and
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Allendorf, 2002, p.8). In order for Haiti to provide usable access towards HIV medication, there
must be a dialogue created so that both female and male may seek for HIV medication without
fear of being turned down due to their gender. Although, the control women have over their
sexual health and body due to their gender is questionable. After all, only recently the United
States- a developed country- allowed women to make decisions of their own sexual health
through the Women’s Health Protection Act (Draw The Line, 2015).
Considering, both genders receiving equal footing in accessing medication the
government must be able to enforce this alternative police. In which, Haiti must find a way to
avoid the same review Bolivia had from human rights ombudsman “that persons with HIV/AIDs
faced the most discrimination in [Bolivia]” (US Department of State, 2008). A possible method
of enforcing an anti-discrimination law would be training authorities in clinics and NGOs on how to
regulate and enforce the law in their environment. However,in order for the authorities to understand the
consequences for violations of the law is via constructing disciplinary review and corrective action forms
that contain such information.
This law will be structured so that there will be degrees of violations on discrimination. Minor
offenses would be regulated by the district in where the clinic is situated. The district would determine
whether or not there was a violation of the law. If there was discrimination in that area,the employer
would be placed on temporary leave until the case has been designated closed. The violators would be
penalized through warning, paying a fine, probation or possible revocation of working in district or
terminating their position in the clinic. This would call in for Federal Court where the Ministère de la
Santé Publique et de la Populaiton or Ministry of Public Health and Population (MSPP) would
determine whether major offenses had occurred against the law. Major offenses would include a
group of complaints were addressed against the clinic. Some of the qualified offenses would be fraudulent
data on patients being served or lack of educating against discrimination during employee training. The
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penalties for these offenses can lead to jail time for the designated employers starting at 5 years or
replacement of the clinic.
Moreover, providing a concise policy on consequences for violation of the anti-
discrimination law will ensure that the abuser of the program will be managed and controlled
efficiently by the establishment ("Enforcement Policy Statement", 2009). Therefore, with the
government passing the anti-discrimination law with enforced regulation, they will promote
and achieve sustained compliance with the law because the law will secure that clinics and
NGOs whom fail to follow their responsibilities shall be held accountable either in court or
through a fine depending on the severity of the violation.
Alternative 3: Reconstruction on transportation
A different blockage of HIV medication Haiti faces, because of 2010 earthquake, is the
loss of the majority of their infrastructure, including clinics and roads. The government must sign
a contract with a foreign country that reconstructs necessary roads to increase medicinal and
structural accessibility. There is also a dire need for isolated villages not near clinics to have
improved roads so that clinics may broaden their reach of HIV patients being able to distribute
their “Van clinics” on a weekly basis efficiently. Additionally, transportation of the HIV
medicine to different clinics would be fast compared to previous years due to the accessibility to
paved roads. Overall, the journey for the patient and drivers to the ART would be less dangerous
and quicker.
However,the government had some opportunities in creating roads across Haiti yet
one notably had lead up to lawsuits. The lawsuits occurred because reconstructing the transportation
network in Haiti is complicated by an inadequate land titling system (Ferriera,2013). In order for
this alternative to become feasible the Haitian government must increase the control the National Land
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Registry Office (ONACA) has in receiving and organizing said land tittles into the system so that the
disputes will not occur.
Another question about the feasibility of implementing this alternative is question on why a
country would want to invest in Haiti. One of the main reasons to invest in Haiti would be creating
political with Haiti. A strong contender on that would be seen through the example from China. Reason
for this is that Haiti is one of the twenty-five countries left in the world that has diplomatic relations with
Taiwan lieu of the People’s Republic (Moody, 2010). In fact,china was the first to reach Haiti in
providing a 125 member search-and-rescue team,aid supplies and medics when the earthquake in 2010
(Embassy of People's Republic of China in United States, 2015). It is also possible for China to
have a stronger influence in creating relations with Haiti versus the United States because they
are trying to avoid the imperialistic/colonial approach of a better country offering “foreign aid”.
This is good since Haiti is well known in having pride of being the second independent nation in
Americas and being done through a “negro-slave” revolt ( History.com Staff, 2010). Instead,
China is trying to offer help to it is familial country in their time of need by not providing
excessive amount of debt or loans and creating a contract between partners (Moody, 2010).
Moreover, some critics about this alternative claim that initially the cost would be too
high- $1.96 billion- since the government would have to rebuild instead of improve roads due to
the earthquake from 2010. Although, if the Haitian government can implement the increase of
roads and transportation, the roads would create jobs and the overall productivity growth would
increase (Bureau of Transportation Statistics, 2015). Increasing the jobs and productivity of Haiti
will increase in the overall economy. This suggests that over time the trade-offs of spending now
in the country's economy will increase the welfare of the HIV patients and overall country in the
future.
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Alternative 4: Implementing HIV education
This alternative policy will be implementing sexual education in schools to help
educate young adults on how HIV is transmitted, how HIV can be prevented and how their
gender roles influence their roles in the spread of HIV. This is a challenge in providing access to
medication because there is only a literacy rate of 60.7% in the entire country's population (CIA,
2015). Although, the importance for this alternative to be implemented is that there is a
considerable amount of youth who are at risk of contracting HIV due to their lack of HIV
education. Education being one of the key factors in preventing HIV makes it considerably
important for the Haitian government to implement a policy that will help create a program on
educating civilians about HIV (Jukes and Dessai, 2005).
Although, poverty in Haiti is making both males and females vulnerable to HIV by
decreasing access of services, like education. This makes it difficult to create a system were the
government can regulate the progress of the program, and pay the sufficient amount of income
for the teachers to provide extra information other than the ones the teachers are trying to teach (
Emmerson, 2011). Critics may question if there is a satisfactory amount of educators who can
provide the teenagers with the HIV information, when Haiti only has a literacy rate of 60% in the
entire country (Emmerson, 2011)? Would the role then have to be forced upon the health
institutions, or the health organization, or could it be possible that they might want to work with
one another (Gupta et. al, 2002, p. 44)? Some suggest that since there are very few educators in
Haiti that this should be enforced by the NGOs.
An example of such a program was established in Uganda, yet implemented by the
government, was called "Abstinence, be faithful, use a condom" campaign or ABC
strategy (Bendavid, 2009).The ABC strategy does appear successful for it was credited in
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decreasing the percentage of AIDS by 10% from 1990 to 2001 in Uganda (Murphy et. al, 2006).
However, by preaching abstinence, the loss of virginity will further increase and support
"negative social sanctions associated with [it]" (Gupta et. al, 2002, p.21). Resulting to teenagers’
curiosity and ability to ask about sexual information almost taboo, let alone HIV.
There was further criticism on this policy strategy because the question whether ABC
was truly responsible for Uganda’s decline in HIV. One of the main points was written by Elain
Murphey and her co-authors stating that there is a well-documented admittance of sexual
violence against women and it is a risk factor for HIV (2006). Haiti may be a religious country,
there is still rape occurring whether one is practicing “Abstinence” or not. Simultaneously, one
of the highest risk groups in Africa were neglected in the ABC strategy based on the "Be
faithful": monogamous married women (Murphy et. al, 2006). Analyzing virtue of sexually
transmitted infections among married men are highly incidental because of extramarital sexual
activity due to recent surveys performed (Murphey et. al, 2006).
Even though there is a sub-population that is being neglected in this strategy, the
education will be focused on pre-teens ranging from 12-15 where one can assume that these
children are not yet mothers. Distinguishing the age category of where the education will be
focused on allows for the policy providing all the government's efforts in
implementing HIV education to that age group. Based on these changes provided by the ABC
strategy, the Haitian government may use the program as a template that supports their strong
values in religion yet informative and affordable.
Overall Outcomes of Alternatives
An outcomes matrix was created based on the evidence provided from each of the
alternatives. The outcomes matrix evaluated the alternatives based on how well the policies
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addressed the problem through the criteria (Figure 3). It is safe to conclude that based on the
criteria both sexual health education and reconstruction on transportation would be useful in
assisting the Haitian government in providing HIV patients accessibility towards medication.
Dependent on the government’s situation one may choose either or both. Reason for this is that
between the two alternatives sexual health education is the best alternative in cost-effectiveness
while the reconstruction on transportation has better political feasibility.
Figure 3: Based on the weights of each criteria, the alternatives were evaluated from being the least effective
(1) to the most effective (5) in addressing the problem through the criteria. Total results represents the overall
outcome of the alternative. HIV treated (.45) + Feasibility (0.275) + Cost-effectiveness (0.275) = Total results.
Discussion
The desired state after one of the following alternatives was chosen was help government
to increase the amount of HIV Medicine being provided to patients leading to better regulation
on HIV epidemic. From the results of the outcome matrix it appears that both the sexual
education and reconstruction of infrastructure would be best in helping the government reach the
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desired state. Based on the economic and social environment it would be interesting on which of
the alternative policies the government would choose.
At first, it was planned to use only one alternative policy yet from this data it would be
interesting to do further research and see how combined policies would alter the results in
assisting in providing HIV medication to the patients in Haiti. If the government would prefer to
have a finite example of how the policies can be implemented there can be further research done
by performing a pilot study. In the pilot study, instead of implementing the entire law in the
entire country, the government can try working with the NGOs. Working with NGOs first allows
the government to see how the alternatives would affect a program like PMTCT. Although by
focusing on a specific program, it allows the government to not invest too much money in a
policy that might not work. Furthermore, the government can put their mark on the program to
include the interest of their citizens and themselves.
Whether Haiti chooses an alternative or not for this pilot study of federal announcement,
the one that the government uses will bring some powerful trade-offs both political and
economic. The question that will be answered overtime is whether or not their choice was the
best alternative for their current epidemic. Through the outcome matrix it appears that the
government will not decrease the accessibility of medication to their people. This is a plus since
the overall goal was to improve the accessibility of HIV therapy to the Haitian people.
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