CRICOS Provider No 00025B Haïti and the Health Marketplace: The Results are Perishable Jo Durham, PhD International Health School of Population Health University of Queensland

CRICOS Provider No 00025B Haïti and the Health Marketplace: The Results are Perishable One of six country case studies examining the provision of health services in severely disrupted environments

The state is so weak (some questioned if the state even existed), it is unable to meet its core obligations of provision of accessible and functional health services and its governance function of regulation making the marketplace unplanned, informal, pluralistic, emergent and inequitable with health reconfigured as a commodity CRICOS Provider No 00025B In Haiti we found..

Secondly Interventions have focussed primarily on supply at the expense of demand and the supporting function of governance, further contributing to market failure CRICOS Provider No 00025B

Outline Brief overview of Haïti Methods Results & discussion Conclusion and further research CRICOS Provider No 00025B

Haïti Disasters and disease outbreaks, violence, social divisions and political instability, have created a succession of “routinized ruptures” Reflected in HDI (0.454, 158/179) and health and social indicators

Total population10,174,000 Gross national income per capita (PPP international $) 1,180 Life expectancy at birth m/f (years)61/64 Probability of dying under five (per live births) 70 Probability of dying between 15 and 60 years m/f (per population) 258/223 Total expenditure on health per capita (Intl $, 2011) 94 Total expenditure on health as % of GDP (2011) 7.9 WHO,

Methods Partly funded by the Danish Ministry of Foreign Affairs, coordinated through the Australian Centre for International and Tropical Health (ACITH) Case study approach: Extensive documentary and policy analysis - peer-reviewed articles, books and “grey” literature In-depth interviews using thematic guide (January and February 2011, N = 45) Thematic analysis and subsequently analysed using a market perspective CRICOS Provider No 00025B

Health system Public, private, traditional Public & private not-for-profit provides coverage to around two thirds of the population Private sector serves around 10% Traditional “available to everyone” CRICOS Provider No 00025B

Discussion Emphasis in Haïti has been on the supply side of health care with the gap in state provision filled by the private sector Limited attention has been paid to the demand side or institutional capacity building The presence of internationally subsidised services has reduced demand for public services The inability of the state to regulate the market has led to market failure, and ineffective, inefficient and unequal allocation of resources and ultimately ruinous health outcomes CRICOS Provider No 00025B

Discussion Emphasis on supply side has undermined capacity of state to fulfil its obligations Has allowed health care to expanded in an unplanned, uncoordinated and unregulated manner & commoditised health Relative over supply of curative services, over-prescription of pharmaceuticals and asymmetrical knowledge between providers and patients Raises questions of transparency and accountability – who are private providers accountable to? Governance dispersed and global

Conclusion Reversing fragility and building resilience & adaptive capacity into the health system needs interventions at multiple levels Need to recognise and harness the wide range of players which provide healthcare with analysis including analysis of broader social and political environment Find ways of building demand side capacity to influence the behaviour of consumers

Conclusion Further research is needed to better understand how to build demand, e.g. how can community networks be leveraged to shape health systems where the state is weak While not without risks need long-term engagement with state Find ways of influencing providers to understand what incentives would motivate the private sector to self regulate Recognise that program design is likely to be emergent and require new ways of monitoring and evaluation – what works in what contexts for who? CRICOS Provider No 00025B

Full report CRICOS Provider No 00025B

Acknowledgements Dr Peter Hill Dr Enrico Pavignani Dr Markus Michael Mark E Beesley, RN Images from global image CRICOS Provider No 00025B

Selected References Bloom, G., & Standing, H. (2008). Future health systems: Why future? Why now? Social Science & Medicine, 66, Bloom, G., Standing, H., & Lloyd, R. (2008). Markets, information asymmetry and health care: Towards new social contracts. Social Science & Medicine, 66, Bloom, G., Standing, H., Lucas, H., Bhuiya, A., Oladepo, O., & Peters, D. H. (2011). Making health markets work better for poor people: The case of informal providers. Health Policy and Planning 26, i45–i52. Cammack, D., McLeod, D., Menocal, A. R., & Christiansen, K. (2006). Donors and the ‘Fragile States’ agenda: A survey of current thinking and practice. Report submitted to JICA. London: ODI. Caple James, E. (2010). Ruptures, rights, and repair: The political economy of trauma in Haïti. Social Science & Medicine, 1, 106–113. Timmermans, S., & Almeling, R. (2009). Objectification, standardization, and commodification in health care: A conceptual readjustment. Social Science & Medicine, 69, 21–27. Tschumi, P., & Hagan, H. (2008). A synthesis of the making markets work for the poor (M4P) approach: UK Department for International Development (DFID) and Swiss Agency for Development and Cooperation (SDC). Zanotti, L. (2010). Cacophonies of aid, failed state building and NGOs in Haïti: Setting the stage for disaster, envisioning the future. Third World Quarterly, 31(5), CRICOS Provider No 00025B