The impact of the 2010 earthquake in Haiti was devastating for a country whose history was already marked by poverty, natural disasters, environmental degradation and political instability. An outbreak of cholera several months later further hampered reconstruction efforts. At the same time, this presented an opportunity to rebuild and develop the country, including an already extremely fragile and inequitable health system. Over five years later, this opportunity seems to have been missed.
This article looks at the state of reconstruction of the health sector in Haiti and some of the major challenges faced, highlighting two issues in particular: 1) the under-prioritisation of health in reconstruction and development and 2) the focus put on rebuilding curative health facilities, such as hospitals and health centres rather than on other key components of a well-functioning health system. Lack of attention to human resources, health promotion and preventative activities and the funding of associated recurrent costs for maintenance, salaries and medical supplies, means that newly rebuilt hospitals and other health structures have remained unused.
2 The earthquake: a disastrous impact on an already weak health system
The earthquake which struck Haiti on 12 January 2010 caused the most severe crisis in the country’s entire history. In addition to massive destruction of infrastructure, hundreds of thousands were killed, wounded or displaced. Damages and losses, estimated at $8 billion, exceeded the country’s GDP by over 120%.
The health sector was not spared; in the disaster zone, 30 out of 49 hospitals were damaged or destroyed. The Ministry of Health’s main building also collapsed. Many medical staff were killed or left the country shortly after the earthquake, while those who remained struggled to cope with their own losses and desperate living conditions. The earthquake had a devastating effect on a health system, which was already extremely weak and unable to meet needs. At least half of the Haitian population had no access to formal healthcare due to geographical and financial barriers. given the incidence of poverty and a system based on cost recovery, even very low fees were unaffordable. An outbreak of cholera in October 2010 would cause another major unexpected crisis and compound the misery caused by the earthquake.
3 The aid response: hope for the health sector
The massive mobilisation of aid actors that followed the earthquake and the significant sums promised provided much hope for the reconstruction and development of the country. Billions were pledged for relief and recovery (including over $13 billion by multilateral and bilateral donors), in particular at the international donors’ conference held in New York in March 2010 in support of the Haitian government’s plan of action, which set out a vision for reconstruction: to “rebuild Haiti by turning the disaster (…) into an opportunity to make it an emerging country by 2030”.
Five years later, the Haitian context is characterised by decreasing official development assistance and the departure of aid agencies. The pledges made for reconstruction have not all materialised. As is often the case, the crisis has been eclipsed by others. The priority given to humanitarian aid over reconstruction/development is visible in the proportion of funds disbursed. While a large proportion of public funding for humanitarian relief has been disbursed (94%), a much lower proportion (37%) of pledges for recovery has materialised.
Although pledges have not all actually been disbursed, foreign aid for relief and recovery has been significant. Over $6 billion has been disbursed by bilateral and multilateral donors, and some $3 billion has been contributed by private donors to UN agencies and NGOs – in total over $9 billion. Even though it does not amount to what was pledged, this sum is substantial in view of the damages and losses incurred.
Of the funds disbursed, only a limited proportion has gone through the Haitian government (1% of emergency and 9% of recovery funds), side-lining Haitians in decisions concerning their future and missing the opportunity to strengthen government capacity. This is understandable in the immediate aftermath of an earthquake where government capacity is lacking following the loss of civil servants and the destruction of public buildings. However, major concerns about systemic corruption have also contributed to the reluctance of international donors to channel funds through the government. At the same time though, international actors themselves have not always met expected standards of transparency in the use of donated funds. Subcontracting in particular has increased the difficulty in tracking expenditures. For instance, the United States did not specify 64% of the recipients of recovery funding. As Larrimore and Sharkley argue, “it is very hypocritical that the international donor community has been reluctant to fund the Haitian government over concerns of corruption when aid disbursements and lofty contracts are frequently given to NGOs and private contractors that operate with little to no accountability”.
4 Challenges of health sector reconstruction
The main challenge of reconstructing the health sector was to avoid going back to the poor pre-existing situation, the earthquake even representing an opportunity to “build back better” and ensure equal access to quality healthcare.
Specific efforts, such as those of Médecins Sans Frontières and the Brazil-Cuba-Haiti Tripartite collaboration – with its model based on the construction of health facilities but also the provision of medical staff and expertise through the Cuban Medical Brigades – have been laudable. Overall however, coordination, leadership and a coherent approach to planning have been lacking, leaving important health gaps. Health has been under-prioritised in the general reconstruction effort, and within the health sector, the focus has been on rebuilding infrastructure.
4.1 Under-prioritisation of health in the reconstruction effort
The priority given to healthcare in the reconstruction effort is evident in the figure below, which also shows that donor and Haitian government priorities have not always aligned. In some sectors, donor pledges were much higher than government requests (e.g. transportation), while in others they were much lower (e.g. reconstruction, including clearing and dealing with debris). The health sector was in the latter category, although the difference was less important than for other sectors: of the $390 million requested, $320 million was pledged at the New York conference, leaving a gap of some $70 million.As of December 2012, 44.5% of pledges for health had been disbursed and 53.4% had been committed. The lack of financing for cholera control plans is another indication of where priorities failed to align. To date, only half of the $448 million required for the government’s two-year plan has been mobilised by international partners. Some $2.2 billion will be needed to implement its ten-year plan.
The health sector also does not appear to have been one of the Haitian government’s top priorities. Health was not included in President Martelly’s vision for the country, a program based on the five “Es” – environment, employment, education, energy, and état de droit or state of law. Governmental priorities are also reflected in the national budget; the percentage allocated to the Ministry of Health has decreased in recent years (standing at around 5%in 2014-15), further weakening it. This is contrary to the recommendation in the National Health Policy to raise the national budget contribution to the health sector to 15%. Although all public sectors need financial support, the rationale behind decreasing support to a key sector such as health while increasing support to other sectors such as tourism is not clear.
4.2 Failing to focus on key components of a well-functioning health system
The government of Haiti has developed a number of plans for the reconstruction and development of the health sector, aiming to guarantee quality care for all Haitians and covering key areas such as the construction of hospitals, investments in human resources and equipment, and strengthening the management of inputs and medicines. In the last five years, hospitals and health centres have indeed been reconstructed or newly built. The government recently announced that, thanks to the support of its partners, it had been able to rebuild or newly construct 24 hospitals, 88 health centres, 9 specialised centres, 34 diarrheal treatment centres and 15 other structures. Moreover, the construction of 5 hospitals and 17 health centres wasunderway. Other programs and services (i.e. an ambulance service) have also been put in place. These results are undeniably encouraging. However, other components of plans have failed to materialise.
While these results are encouraging, not all essential infrastructure has been fully rehabilitated. The only public teaching and referral hospital for specialty care in the country (l’Hôpital Université d’Etat d’Haïti) is still not totally functional. Qualified staff, funding for recruitment and salaries, as well as drugs and supplies are lacking. Low salaries in the public sector have created an incentive to work in the private sector and absenteeism of staff is also an issue. Due to salary arrears, hospitals have been affected by problems such as strikes. The inability to recruit extra staff has also increased the difficulty of integrating cholera treatment centres run by foreign organisations into Ministry of Health structures. Brain drain increased in the aftermath of the earthquake and continues today, with qualified staff migrating to countries such as Canada and the United States, which are paradoxically also major donors to Haiti. As training activities also appear to be insufficient, the capacity to run new medical structures remains limited, leading to “empty shells” or “ghost hospitals”.
The 2010 earthquake had a disastrous impact on an already fragile health system, and exacerbated existing difficulties in accessing healthcare. The substantial promises made by the international community for reconstruction offered hope, and given the resources disbursed, there was clearly an opportunity to “build back better”.
Improvements have been made, mainly at the level of infrastructure with the reconstruction of numerous hospitals and health structures. In addition, positive results have been obtained in recent years, for example, in the fight against transmissible diseases such as HIV/AIDS, tuberculosis and malaria. Key mortality indicators have kept improving.
However, access to health remains limited in Haiti despite the massive international presence and significant amounts disbursed. Maternal and child mortality rates, for example, remain by far the highest in the Americas. Today, there is even concern that in a context characterised by donor fatigue, the recent termination of aid programs such as the Canadian-funded free obstetrical care program, and the presence of cholera, the health situation of the Haitian population could go back to “square 1” or even “square -1”. Permanent financing and support to maintain health structures and ensure the sustainability of programs are still uncertain.
Haiti has faced many difficulties recovering from the devastation caused by the earthquake and the subsequent cholera epidemic, and the country remains vulnerable to acute emergencies. In order to expand access to health, as well as other crucial areas such as water and sanitation,the capacity of the Ministry of Health and its coordination role must be strengthened. Health must remain a priority for Haiti, and foreign aid must continue to support the country’s new National Health Policy (in French), which sets out a long-term vision for the health system based on equitable access to quality services and care.
Maude Montani (PhD) is Research and Publications Officer at the Research Unit on Humanitarian Stakes and Practices (UREPH), Médecins Sans Frontières Switzerland
 Whereas the government puts this figure at 47%, others argue that the number of patients who had to abandon treatment due to a lack of means must be added, giving a total of 80% (Brauman R., 28 July 2010, Haïti: la médecine privée et les privés de medicine, Libération: http://humanitaire.blogs.liberation.fr/2010/07/28/haiti-la-medecine-privee-et-les-prives-de-medecine/).
 Cholera remains a major public health issue, and it can be expected that more limited outbreaks will continue to occur as the disease becomes endemic. The number of cases has reached a stage where the Ministry of Health could take the lead, however its capacity to respond to any increase in cases is still lacking. Despite overall cholera fatality rates below the WHO global threshold, cholera related fatality rates in hospitals have increased due to the weak capacity of health centres to provide care to cholera cases and the closure of dedicated cholera treatment centres.
 Figures on funds pledged and disbursed are those compiled by the Office of the Special Envoy for Haiti: http://www.lessonsfromhaiti.org/ Figures are as of December 2012, the most recent compilation of figures available. It is therefore possible – even probable – that the amounts disbursed as of today are greater.
 See also Ramachandran V. and Walz J., 2012., Haiti: Where Has All the Money Gone?, CGD Policy Paper 004, http://www.cgdev.org/files/1426185_file_Ramachandran_Walz_haiti_FINAL.pdf
 Haiti Libre, 6 Sept. 2014, Impressionnant bilan du Ministère de la Santé: http://www.haitilibre.com/article-11990-haiti-sante-impressionnant-bilan-du-ministere-de-la-sante.html?utm_source=dlvr.it&utm_medium=twitter MSPP, Réalisations du MSPP 2011-2014: http://mspp.gouv.ht/site/downloads/Realisations%20MSPP%202011%202014%20avec%20appui%20partenaires%2014%20sept%2014.pdf
 Charles J., 1 Nov. 2014, Haiti’s new $83 million General Hospital still not built, Miami Herald: http://www.miamiherald.com/news/nation-world/world/americas/haiti/article6006105.html
Ganyelar L, 22 March 2013, Lack of Doctors and Basic Resources Plagues Haiti’s Public Health System, Global Press Journal: http://www.globalpressjournal.com/americas/haiti/lack-doctors-and-basic-resources-plagues-haiti-s
Gaestel A., 12 Jan. 2015, Still Fissured: Haiti’s Health System, Five Years After the Earthquake, Los Angeles Review of Books: http://lareviewofbooks.org/essay/still-fissured-haitis-health-system-five-years-earthquake
Porter C., 16 Feb. 2015, Lovely’s Haiti: Another crisis, another miracle, thestar.com: http://www.thestar.com/news/world/2015/02/16/lovelys-haiti-another-crisis-another-miracle.html