Docuent of

The World Bank

]FOt oMcAL uSE ONLY

Report N.. 5699-CRG

HAITI

SITUATION NOTE ON THE

POPULATION, HEALTH AND NUTRITION SECTORS

May 31, 1985

Population, Health and Nutrition DepartmentIThis gcu.eu it a a mtxfArtma dlsrbujom and may be used by rec4ipiens mly ini the performance oft*ei oBdal di. s _mnmts may nt ohewie be dEsdoed withou Wol Bank au}b _m-.

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CURRENCY EQUIVALENTS

(as used in this report)

Currency Unit = Haitian Gourdes

US$ = G$5

GOVERNMENT OF HAITI FISCAL YEAR

October 1 - September 30

FOR OMCAL USE ONLY

HAITI

SITUATION NOTE ON THE

POPULATION. HEALTH AND NUTRITION SECTORS

TABLE OF CONTENTS

Page No.

ACRONYMS

SITUATION NOTE ON THE POPULATION, HFALTH AND NUTRITION SECTORS . . 1

Sector Status . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Policies and Programs. . . . . . . . . . . . . . . . . . . - . 3

Sector Finance . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Problems, Issues, Options . . . . . . . . . . . . . . . . . . . . 7

Intersectoral Issues . . . . . . . . . . . . . . . . . . . . . . . 10

Donor Coordination . . . . . . . . . . . . . . . . . . . . . . . . 12

Concluding Note . . . . . . . . . . . . . . . . . . . . . . . . . 12

Tables and Figures . . . . . . . . . . .. . . . . . . . . . . . 13

MAP

This report was prepared from information gathered during a sector reviewmission conducted in August/September 1982 by Mr. W. P. NcGreevey. Aprevious report prepared by Mansgement Sciences for Health for the WorldBank provided mucb of the necessary background material. That reportis on file at the World Bank. J. Allman provided recent data and materialto update the report in February-March 1985.

This doument has a tricted distribution and may be used by recipients only in the performance orI ir offKia dutiets contents may not otherwise be discsed without World Bank authorization.

ACRONYNS

WA PCo - Agence d'approvisionnement de pharmacies communautaires,Agency for Supplying Conmmnnity Pharmacies

AOPS - Association des oeuvres privies de sante,Association of Private Health Organizations

DON or EDE - Bureau de nutrition, DSPP,Bureau of Nutrition, see DEEM

CANE? - Centrale autonome 3etropolitaine d-eau potable,Metropolitan Water Supply Company, Port-au-Prince

CAT - Campagne anti-tuberculose,Campaign Against Tuberculosis

CERN - Centre d&iducation et de rxhabilitation nutritionnelle,Nutrition Rehabilitation Center

DRF - Division d-bygi&ne familiale, MSPP,Division of Family Hygiene, see DEFN

DEPN - Division d-hygiene fauiliale et nutrition (DHMN),Division of Family Hygiene and Nutrition

DSPP - D4partement de la sante publique et de la populaticn,Department of Public Health and Population, see 'iSPP

EEC - Communaute economique europeenne,European Economic Community

KARZA - Engineering CompanySociete d'ingenierie

HAS - ESpital Albert Schweitzer,Albert Schweitzer Hospital

HFS - Enquete haitienne de la fecondite,Haitian Fertility Survey

IRSI - Institut haitien de statistique et informatique,ex-Institut haTtien de statiatique (IRS)Haitian Institute of Statistics and Computer Sciences,formerly Haitian Institute of Statistics (IHS)

MSPP - Ministere de la sante publique et de la population,Ministry of Public Health and Population, formerly DSPP

ONAAC - Office national d'alphabetisation et d'action communautaire,National Office of Adult Education and Coammnity Development

REDS - Rural Eealth Delivery System Project,PSPSS Projet de systeme de prestation de soins de sante en

riilieu rural

SNEH - Service national des endemies majeures,ex-Service national d'eradication de la malaria.,National Service Against Major Endemic Diseases

ELM

Situation Note on the Population. Health, and Nutrition Sectors

1. In 1985 Haiti ranks 18th on the Bank-s list of 28 Low-incomecountries (per capita product = $320 in 1983). It is one of the poorestin the world. Between 1960 and 1982 per capita income grew 0.6 percentper annum and its population density increased from 164 to 179 per squarekm., despite significant emigration. In rural areas, farm implementsand production techniques remain those of two centuries ago.

2. Haiti ranks poorly in terms of life expectancy at birth (53),infant mortality (120 per 1,000 live births in 1984, according to theHSPP) and percentage of children with second-or-third degree malnutrition(27.3 percent). Its crude birth rate (36) and total fertility rate(4.6) are comparable to countries of similar income level in Africa.Over one-quarter of Haitian women did not breastfeed their infants duringthe most recent birth interval and 90 percent of deaths among children,1-4 years of age, is caused by malnutrition and diarrheal diseases.

Sector Status

Population

3. The total population of Haiti is over five million accordingto the 1982 Census, and is now growing about 1.8 percent per annum.Port-au-Prince, with a population of 750,000, is ten tines larger thanCap-Baitien, the second largest city. Over 15 percent of persons bornHaitian, about one million persons, now live outside the country. TheWorld Bank estimates that total population will grow to 7 million bythe year 2000 and 13 million by the year 2050. With more rapid fertilityand mortality decline than is now projected, population in the year2050 could be held to 10 million. A recent Bank report on the agriculturalsector calls attention to declining agricultural resources in relationto population; the population-resource balance in rural Haiti will growincreasingly unfavorable unless effective measures are taken to slowpopulation growth.

4. Fertility is only moderately high, in part because ofsubfecundity associated with the country's poverty. There is widespreadknowledge of modern contraceptive techniques, but only five percentof married women were found to be using modern methods of fertilitycontrol in a 1983 survey. Pilot experiments demonstrate considerabledemand for family planning; the high levels of knowledge of modern methods,and the widespread use of traditional but ineffective contraception,both suggest a context favorable to the introduction of modern, effectivemethods. The World Bank estimates the unmet need for contraceptionto be between 13 and 30 percent of all eligible women.

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Health

5. The death rate has fallen somewhat in Haiti, from above 16per thousand population in the early 1970s to about 13 currently. Thatlevel is much higher than that which prevails in the rest of Latin America.Similarly, life expectancy is ten or more years less than among Haiti'sneighbors in the Caribbean. Outside Port-au-Prince there is but 1.4.physicians for each 10,000 persons. As a result, only a fraction ofpeople who need treatment receive it. Preschool children are sick abouthalf the time; 80 percent of this illness is diarrhea. The vast majorityof illness and death in Haiti is related to undernutrition and to infectiousdisease which could be p=evented by immunization.

6. Infant mortality is high and higher in Port-au-Prince (about150 per thousand live births) than in the countryside (about 120), inpart due to migration toward that city and in part due to deterioratingwater supply and sanitation conditions there. The most common causesof death and morbidity are diarrheas and gastroenteritis, tetanus, measles,tuberculosis, malaria, intestinal parasites, pneumonia and respiratorydiseases, typhoid and poliomyelitis. Infant deaths are due principallyto diarrhea and pneumonia.

7. With respect to adult morbidity, malaria is the most frequentlyreported cause of illness, followed by pneumonia, bronchitis, diarrheas,and malnutrition. Typhoid, syphilis, intestinal parasites, and respiratorytuberculosis are diagnosed about half as frequently as malnutrition.Other common causes of ill health are anemia, infections of the ear,eye or skin, complications of childbirth and postpartum problems, alongwith complaints requiring abdominal surgery.

Nutrition

8. Malnutrition is one of Haiti's most serious health problems;according to the 1978 Nutrition Status Survey between a quarter andhalf of all Haitian children suffer from second- or third-degree malnutritonon the Gomez scale of weight for age. About 30 percent of rural childrenand 48 percent of urban children are anemic. Poverty, food shortages,droughts and floods and feeding practices (only one meal a day, bottlefeeding without potable water) all contribute to malnutrition. Feedingpractices may explain the excess of urban over rural infant mortality.

9. Pilot projects in Haiti have confirmed the synergism betweenundernutrition, gastroenteritis, and broncho-pneumonia, the latter twobeing identified as the leading causes of death. Preschoolers whoseweight for height was more than two standard deviations below the meanhad double the prevalence of fever and diarrhea of those who had grownnormally. These facts demonstrate that curative approaches to healthproblems are undermined by lack of food.

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Water and sanitation

10. Potable water is available to only a minority of households.The fourteen urban systems do not treat water and, witb the exceptionof a few project areas assisted by external donors, rural areas dependon polluted streams, pits and shallow wells. Less than 3 percent ofthe urban population have household sewer connections, and only 13 percenthave an adequate means of sewage disposal. Projections for the year2000 foresee that only 8 percent of households in Port-au-Prince willhave sewer connections. Urban slum dwellers live in overcrowded conditionswithout potable water and sewage disposal; their environment makes goodhealth difficult to achieve.

Policies and Programs

Population

11. The outlines of a population policy appeared in the five-yearplan, 1981-86, published by the Government of Haiti. It contains neitherfertility-reduction targets nor family planning service delivery goals.In 1984, the President of the Republic of Haiti stated his government'scontinued concern with rapid population growth, especially theconstraints that high fertility pose in regard to social and economicprogress. He called ror a reduction of the crude birth rate to 20 per1000 by the year 2000, fertility of three children per woman, a crudedeath rate of 8 per 1000, an infant mortality rate of 50 per 1000 anda life expectancy of 65 years. These guidelines are reflected in theNew Orientation of the Department (now Ministry) of Public Health andPopulation (DSPP) announced in 1982.

12. The Division of Familv Hygiene (DHF) of DSPP began familyplanning work in the early 1970s and shifted in 1977 to a non-clinicorientation, including mobile teams, commercial retail sales ofcontraceptives and use of community agents. DEF established a commuritydevelopment section in January 1979. Contraceptive distribution increasedbetween 1979 and 1982 thanks in part to cooperation witb the Haitianarmy. In 1983-84, a pilot project using SNEM (the endemic disease controlservice) volunteers in Hiragoane also produced dramatic increases inuse of family planning in this area.

13. Family planning outreach efforts at the DHF were reduced in1983-84 since the regions and districts were expected to play a majorrole in service delivery. DHF was to assume a normative rather thanan implementing role. Lack of coordination during the implem6ntationof this change led to reduced family planning service delivery. Boththe 1983 DEF Annual Report and the 1983 contraceptive prevalence surveyindicate very lov levels of contraceptive use in 1983.

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Health

14. The New Orientation, a health policy enunciated by the Ministryof Public Health and Population (HSPP) for the period 1982-86, emphasizesprimary health care as the strategy to reach the MSPP-s objectives.It identifies six priority areas for ministry action: (1) Diarrhealdisease control; (2) immunization against communicable diseases; (3)tuberculosis control; (4) improvement of nutritional status; (5) maternal-child care and family planning, and (6) malaria and endemic diseasecontrol. According to the New Orientation, and its revised and correctedJune 1984 version, special attention will be given to each of the priorityareas during a specified period of time. Thus, as a test case of thisapproach, the diarrheal disease control program was launched nationvidein July 1983. Using social marketing and the mobilization of a broadrange of health. community, commercial and development personnel, thisprogram led to widespread knowledge of oral rehydration, considerableuse of commercially available packets of oral rehydration salts, andreduction in diarrhea cases presented for treatment at health facilities.

15. Malaria has increased sharply in Haiti in the past severalyears. From 41,252 cases recorded in 1979, there were 72,750 casesreported in 1984 according to official data. A 1980 evaluation of SNEKby USAID urged a return to a policy of containment to replace theunvorkable policy of eradication. The 1984 mid-term malaria programevaluation mission stated that the figures for malaria cases wereunderestimated. The mission recommended expanding the number of voL inteersfrom the current 7,000 to 18,000.

16. MSPP will focus on improving immunization coverage in 1985.Tuberculosis, malnutrition, and family planning are scheduled for specialattention in the years ahead. Decentralization, regionalization anddevelopment of the referral system are administrative measures now beingtaken to improve program efficiency.

Nutrition

17. Unlike the sectors of population and health, responsibilityfor nutrition is not consolidated in a single ministry. NSPP, the Ministryof Agriculture, and the Ministry of Plan all play roles in nutritionactivities. Perhaps as a result of the dispersion of responsibilitiesthere is no general nutrition policy guiding government programs inthis area.

18. The Division of Nutrition of DSPP offered nutritionalrehabilitation to several thousand children in 1980, a tiny fractionof all those presumably needing care. Nutrition centers were filledvirtually to capacity. However, rehabilitation was costly and did littleto prevent recurrence of malnutrition. A new rural health deliveryservice project follows a comprehensive, integrated approach to preventivenutritional care including growth monitoring and education. The curative

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approach of past nutrition action programs is gradually being replacedby a grovth-monitoring and surveillance program which forms part ofthe rural health delivery system (REDS) project. This preventive-careprogram envisages timely, targeted, low-cost interventions which couldresult in cost-effective nstional nutrition programs in the future.

19. The Division of Nutrition was merged with the Division ofFamily Hygiene in Jannary 1984, becoming the Division of Family Vygieneand Nutrition (DHFN). Results of the growth monitoring activities conductedin 1982 and 1983 in the South region are being evaluated, and plansare being made to implement the approach in collabor-ation with regionsand districts.

ProRram Facilities

20. There are 467 population, health, and nutrition facilitiesin 1985, 85 of them hospitals and health centers with beds, for manyof which the occupancy rate in 1982 vas less than 50 percent. In 1985there are about 622 physicians employed by the DSPP; over half of theseare located in Port-au-Prince. Thus, areas outside the capital hada ratio of 1.4 physicians for 10,000 people. Over one-fifth of allgovernment employees work for MSPP; the ministry is, after the Ministryof Education, the second largest employer in Haiti.

21. Private health establishments, many of them run by externallyfunded private voluntary organizations, make up almost 50 percent ofthe health facilities in Haiti. Most of these facilities are locatedin isolated rural areas, and many of them serve the poor and needy.Cooperation and ^ division of labor between them and the governmenthas begun recently. An important step was the establishment of theAssociation of Private Health Institutions (AOPS) in April ,82". AOPSmembers have agreed to adopt the priorities and norms of MSPP. Theministry in turn is recognizing the responsibility of private institutionsto provide health services in specified areas of the country.

22. AGAPCO, the Agency for Community Pharmacy Supply, is anadministratively self-contained program of the MSPP that has beenestablished for the purpose of procuring, distributing and selling lowcost generic drugs on a nationwide basis. AGAPCO sells 80 items atregulated prices through over 130 community and institutional pharmacies,the first of which opened in September 1982. The revenues from salesare reserved for the purchase of replacement stock and payment of theprograms's operating costs. There may be a potential for eventual financialself-sufficiency. AGAPCO drug supplies at clinical facilities haveimprovemed the quality of health services. By maintaining an adequatedrug supply, AGAPCO is attracting more patients to existing facilitiesand lowering the treatment cost per patient.

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Sector Finance

Sources of Finance

23. Population, health and nutrition services are financed inessentially similar ways, and they are treated together in this discussion.Eighty percent or more of public expenditures in these three sectorsare devoted to health, at most twenty percent is spent on populationprograms, and less than five percent on nutrition programs. Greaterexactness is not possible because of the overlapping nature of maternaland child health and diarrheal control programs which are related toall three sectors discussed here. Three sources and modes finance canbe identified: (1) Households pay directly to providers; (2) tax revenuespay for the current operating expenses of MSPP and international donorspay for the bulk of the ministry's development budget; finally, (3)private and public external funds pay for current operating expensesof many private clinics, particularly in rural areas.

24. In light of Haiti's overall poverty, the country's expendituresfor population, health and nutrition are substantial. It 1981, healthrelated expenditures amounted to 4.7 percent of GNP, about US$15 perperson. The government's share of sector expenditures is split half-and-half between tzx revenues and rternal grants. Private individualsdirectly finance nearly 60 percent of health care received. Some 99registered private and voluntary organizations operating over 200 facilitiesprovide a large but indeterminate share of sector resources.

External Assistance

25. The principal donors in these sectors, USAID, IDB, WHO/PAHO,UNICEF, and UNDP/UNFPA, provided about US$8 million in 1980 and similarlevels of assistance in more recent years. IDB has supported constructionof hospitals and health posts. USAID and UNFPA support DHFN populationprograms. UNICEF and WHO assist in strengthening health delivery.USAID is also assisting the rural health delivery system and organizationand management improvement for MSPP. Budgets of the programs the differentdonors support were handled separately by vertical programs in the recentpast. There is still insufficient coordination in planning assistance.

26. Some 99 private and voluntary organizations make a substantialcontribution to population, health, and nutrition programs in Haiti.Their dispensaries are often in isolated, rural locations accessibleto the most needy. Since 1982 the Association of Private HealthInstitutions, AOPS, has worked closely with MSPP. This positivedevelopment should be encouraged; it offers the prospect of specializationby level of service in which MSPP could provide adequate secondary-levelhospitals to which patients from the private dispensaries and clinicscould be referred as necessary.

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Problems. Issues. Options

Efficiency and Equity

27. The last five years have witnessed major efforts to introducebasic primary healt'I care interventions throughout the (SPP system.Decentralizatioi, regionalization,the expansion of community healthworkers and the strengthening of private and volunteer participationin health care, have been major accemplishments. Nevertheless, themost urgent problem in these sectors is still the low level of efficiencyin providing basic services. In population, cost per user is exorbitantlyhigh, coverage is low, and unmet need for family planing is doubleor quadruple current use of modern methods. In heal.h, curative careis costly, facilities are understaffed, underequipped, and hence underutilized;most people who need services cannot get them. In nutrition, curativeapproaches have proven too costly, preventive programs have moved littlebeyond pilot efforts, and Government has dispersed responsibility amongtoo many agencies.

28. Similarly, in spite of a major rural health delivery effort,equity is also of concern because of the significant rural-urban andregional disparities in service availability which still exist. Thegeographic distributiou of services dispensed through HSPP is inequitable:too much is spent in the Port-au-Prince area, too little benefits ruralHaiti. Inequity and lack of coverage cannot be corrected without greaterefficiency. Extension of coverage within current budgetary restrictionswill require giving up some services, achieving greater efficiencies,or some combination of the two.

29. Expenditures on population, health, and nutrition strvicesby the government were 16 percent of central government expenditure(that is, excluding state-owned enterprises) in 1981. That share isfar higher than the average for low-income (2.9 percent of centralgovernment expenditure) or even for middle-income economies (5.3 percent).It may be unrealistic to expect the government to spend any more ofits resources in this sector. Thus greater efficiency in resource usein each of these three sectors is essential as a prelude to improvingequity a-od extending coverage.

Population Issues and Options

30. Of the three sectors, population should be assigned highestpriority for several reasons. Contraceptive prevalence has fallen andmust rise to meet population policy goals. Total forest area is shrinkingby five percent per annum. Population growth is an immediate, as wellas a longer-term, development problem, as illustrated by the flightfrom the island's poverty as farm opportunities shrink with soil erosionand tree cutting.

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31. Until the 1980s, the Government of Haiti shoved little concernfor population growth and the unfavorable balance between resourcesand population. More recently, the government has been more emphaticon the need to slow population growth. Fever pregnancies can havebeneficial impacts on both health and pGpi3lation growth. A strongpopulation policy which specifies the measures to be taken to reducefertility rates and population growth is vitally needed at this time.

32. The MSPP has recently established a Directorate of Populationto work with other key ministries, such as Plan and Agriculture, concernedwith future trends in population dynamics and nutrition. There is clearlya need to reverse the decline in family planning service delivery thathas occurred in the last few years. The integration of DHFN supervisionand supply functions into the ministry's decentralized system has createdmany problems. MSPP must now seek an effective management system toincrease the contraceptive prevalence rate by meeting the large andgrowing unmet need. Some combination of vertical and horizontal servicedelivery may be essential. Full integration of family planning actioninto regional management may be possible only after programs of stafftraining. MSPP will need to assure that emphasis on maternal and childhealth is not diminished when it is combined with other health actionsat the regional level. Population programs, as well as other programsof preventive health care, need continued nurturing and strong supportfrom the central management of MSPP and technical backstopping fromDHFN.

33. A thoroughgoing population plan would include population projectionsat least 30 years into the future, along with analysis of the implicationsfor future income growth, agricultural development, urbanization, theenvironment and health status, of alternative population growth rates.The 1981-1986 plan provides no systematic link between program actions,investments in population-growth reduction and intended outcomes withrespect to demographic variables. Such an exercise would complementand reinforce actions at the operational level by MSPP.

Health Issues and Options

34. Within the health sector, government policy gives priorityto primary health care. It &ims to strengthen rural health servicesand to decentralize the management and provision of health services.These goals are acknowledged to require an upgrading of MSPP management,logistics, information, training and supervision at all levels. Thereis very inadequate coverage of the population in need. Only 50 percentof women eligible for prenatal services receive them. The number ofvaccinations given confers protection against diphtheria, pertussisand tetanus to but 5 percent of the under-fives. Productivity andutilization of facilities is very low: dispensaries in one districthandled an average of only five clients per day in 1979. There is roomfor considerable improvement in the productivity of both health workersand health facilities.

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35. Government policy in favor of primary health care is not reflectedin its spending. Curative hospital services may absorb as much as eightypercent of the ministry budget; too small a share is devoted to primarycare, particularly for the rural poor. Given resource constraints,one means to improve primary health care is to save money now spenton curative care. Thus there is an urgent need to make more efficientuse of existing hospital resources. One option is to increase bed occupancyratios from a current low level of 36.5 percent. This can be accomplishedby concentrating limited personnel resources in fewer facilities. Toincrease efficiency there needs to be a more intensive use of dispensariesand health centers. The devolution of some tertiary care to privateproviders, and some forms of private or social insurance to financehealth care, should be considered.

36. MSPP has made progress in restructuring its personnel andmanagement. A remaining need is to assign a higher proportion of MSPPstaff to the delivery of health services. Recent progress made by MSPPin analyzing how resources are currently being allocated (in terms ofpersonnel distribution, salaries, budget, logistics and supply, andtransport) and in improving statistics on health status, should be continuedand consolidated, in order to increase productivity at the central ministryleve'l and in the newly organized regional and district health offices.

Nutrition Issues and Options

37. The fundamental constraint to improving nutrition status isthe shortage of food and the pervasiveness of poverty which blocks poorHaitians' access to the limited food available. Families do not wastefood: a long-term solution to Haiti's problem of undernourishment dependson income and productivity growth. Food aid has in the past posed seriousmanagement demands in Haiti, and the objectives of that aid have notalways been met.

38. Given current government priorities, as reflected in the patternof expenditures, it seems unlikely that a major effort can be made toimprove nutritional status. Feeding programs, food subsidies, and pricepolicies aimed at helping the poor get enough to eat are beyond therange of possibility at this time. Nonetheless it is important torecognize the seriousness of the malnutrition problem. Long-termdevelopment will be impossible if children are wasted and stunted, thusentering school age unable to learn. More effective government responseto nutritional needs could be achieved with better coordination betweenministries which now share responsibility for service delivery and nutritionplanning.

39. Immunization, growth monitoring, oral rehydration, and promotionof breastfeeding are central components of the primary health care systemin the pilot programs developed so far in Haiti. These offer some hopeof ameliorating nutritional problems and represent an advance over earlier

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programs that were too costly per child served. These programs requirefurther testing and evaluation. If found to be financially feasiblewith respect to the recurrent costs which they generate for MSPP, theyshould be expanded. Such programs can then help compensate for thevery low level of financial support which has in the past been devotedto nutritional needs. Malaria workers currently distribute chloroquineonly, but they could be trained te distribute packets of oral rehydrationsalts and family planning materials. This change would allow greatlyexpanded coverage of both the diarrheal diseases control activitiesand family planning. The volunteers no longer collect blood sampleson slides to monitor malaria, so the 1984 USAID evaluation concludedthat these new activities would not involve more time spent by the volunteers.Building on the SNEM volunteer system could help spread low cost primazyhealth care to rural areas.

Intersectoral Issues

Sectoral Balance

40. A major sector policy choice is the balance to be struck betweenprogram efforts in population, health, and nutrition. MSPP budgetsand staff resources are used predominantly for health services. Itmay be possible to tilt resources more in the direction of populationand nutrition programs and at the same time address basic health careneeds more effectively.

Sector Financiinx

41. The issue of how to finance population, health, and nutritionprograms is fundamental to the effective management of these sectors.The operating and development budgets of the Gover nent of Haiti areoften analyzed separately. In the case of MSPP, this approach isunsatisfactory for two reasons. First, expenditures for wages, salariesand materials by DHFN, SNEM and other projects are counted as part ofthe development budget even though much of these costs should be partof the operating budget. To refer to such expenditures as developmentor investment understates the financial costs of maintaining day-to-dayservices in these sectors. Second, today's development-budget projectscreate the need for tomorrow's recurrent costs in the operating budgetas donors seek to transfer th2 burden of paying for project activitiesonto the operating budget of the Government of Haiti.

42. Currently planned development expenditures will require verylarge operating expenditures in the future. These amounts may exceedthe resources which the Government of Haiti can devote to this sector.The inability to finance an adequate level of operating expendituresis currently a serious cause for concern. What money there is in theoperating budget goes almost entirely for wages and salaries (87 percentin FY84), thus limiting the complementary services, such as drugs andmedical tests, and essential maintenance. Projections made in 1983

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(Table 4.1) suggested that public expenditures would grow significantlyin the 1980s: In 1983 by 22 percent; in 1984, by 15 percent; in 1985and 1986, by 10 percent. The rapid increases arise because projectsin the development budget require increased expenditures in the operatingbudget as the projects are brought into normal operations. These includesuch valuable projects as rural health delivery, malaria control, health-centermaintenance, and maternal and child care, all of which merit supportwithin normal ministry operations.

43. International donors are reluctant to finance recurrent costs.When grant funds provided by bilateral donors are applied to recurrentexpenditures, there are strenuous efforts made to guarantee that theGovernment of Haiti will be prepared to pay staff when the grant isconcluded. Thus even grants eventually require that program expendituresbe paid from government tax revenues. The share of taxes spent on thesesectors is already high; therefore, it may not be feasible for spendingin this sector to rise as fast as is projected. Options to be studiedinclude greater efficiency in service delivery, some means to inducerecipients of service to pay some part of their cost, and the shiftof some services to the private sector so that th1ey would not constitutean excessive burden on limited tax revenues.

Personnel Planning

44. The internal efficiency of service delivery in the population,health, and nutrition sectors is far lower than could be obtained.Before any consideration can be given to augmenting sector resources,further improvements in efficiency are both possible and essential.This will entail changes in NSPP personnel management and structure.Although there are over 10,000 MSPP checks issued each pay period, thereare important, unmet needs for technical staff outside the capital.Almost half the ministry staff are administrative or other, and no mechanismexists for paying the salaries of health agents, the base of the primaryhealth care system, when external funds are not available. Rural healthservices can be delivered effectively and at lower cost by volunteers,auxiliaries, and nurses than by trained physicians who are needed onlyfor referrals at higher levels of service. One means to assure thatskill levels are consistent with rural program needs is to complementthe planned administrative decentralization with a decentralizationof employment. Such a move would be consistent with the general Governmenteffort to move activities out of the capital. A review of staffingneeds in MSPP in light of priority attention to primary health careis essential. The review should also consider the social service programin order to make better use of the one-year service required of medicalschool graduates.

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Donor Coordination

45. More effective donor coordination by the Government of Haiticould help to increase the efficiency of resources devoted to thesesectors. It could also lead to the mobilization of additional resources.Many of the agencies in the donor conmmunity favor of augmenting assistanceto Haiti in the population, health, and nutrition sectors. Greaterassistance ought to be contemplated if the government can effectivelyaddress the difficult issues identified in this report.

Concludinu Note

46. This brief overview offers only an introduction to thepopulation, health, and nutrition sectors in Haiti. More analysis ofsuch topics as nutritional interventions, equity of service delivery,efficacy of vertical versus horizontal sytems of management, and theeffectiveness of public and private organizations in this sector isneeded. Systems of drug supplies, employee compensation, and productivityare all topics that would require more intensive study in the future.

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LIST OF TABLES AND FIGURES

Page No.

1.1 - Summary of Population Statistics from Several Sources . . . 17

1.2 - Percentage Distribution of Women Ever in Union Aged 15-49Years Reporting Knowledge of a Contraceptive Method,1977 HFS . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

1.3 - Infant Mortality Rates (per 1000) for Port-au-Prince, RuralAreas in Haiti by Five Year Cohorts of Hales and Femalesfor the Period 1956-1976, 1977 BFS . . . . . . . . . . . . . . 19

1.4 - The Components of Population Growth Rate in Haiti,1970-2000 . . . . . . . . . . . . . . . . . . . . . . . . . . 20

1.5 - Causes of Death, All Ages . . . . . . . . . . . . . . . . . . 21

1.6 - Cause of Death, by Age, H6pital Albert Schweitzer, 1980 . . . 22

1.7 - Haiti: Prevalence of Undernutrition by Region, 1978 . .23

1.8 - Comparative Indicators of Population, Health and NutritionStatus, Haiti and Selected Countries . . . . . . . . . . . . . 24

3.1 - Distribution of Health Facilities and MCH/FP ClinicalOutlets by Geographic Region, 1980 . . . . . . . . . . . . . . 29

3.2 - Expenditures on DSPP Health Services at District Level,FY78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

3.3 - Health Personnel in Haiti in All Sectors . . . . . . . . . . . 31

3.4 - Some Indicators and Comparators for Health Personnel andSector Productivity, 1981 . . . . . . . . . . . . . . . . . . 32

3.5 - Haiti: Salaries of Civil Servants by Administration, 1978 . . 33

3.6 - Division of Family Hygiene Staff - Central office andField June l978 . . . . . . . . . . . . . . . . . . . . . . . 34

3.7 - Average Daily Dispensary Utilization by Province - 1979 . . . 35

3.8 - Distribution of Visits Among Regions/District, 1979 .36

3.9 - Percent Distribution of Patient Contacts by Type of HealthFacility - 1979 . . . . . . . . . . . . . . . . . . . . . . . 37

-14-

Page No.

3.10 - Percent Distribution of Patient Contacts by Category ofContact, 1979 . . . . . . . . . . . . . . . . . . . . . . . . 38

4.1 - Haiti: Population, Health and Nutrition Budgets forOperating and Development Expenditures, FY77-'Y86 . . . . . . 43

4.2 - Projected DSPP Budget de Fonctionnement . . . . . . . . . . . 44

4.3 - DSPP Operating Budget for FY81 . . . . . . . . . . . . . . . 45

4.4 - DSLP Development Budget for FY81 . . . . . . . . . . . . 46

4.5 - Global Budget for the Realth Sector for 1981-1986 . . . . . . 47

4.6 - Haiti: Donors in Health, 1980 . . . . . . . . . . . . . . . 48

FIGURES

1.1 - Percent of Children 3 to 59 Months with Second or ThirdDegree Malnutrition . . . . . . . . . . . . . . . . . . . 25

3.1 - Organigramme - Departement de la sante publique et de lapopulation (DPP) . . . . . . . . . . . . . . . . . . . . . . 39

3.2 - Distribution of Health Manpower in the Health InfrastructurePyramid . . . . . . . . . . . . .. . . . . . . . . . 40

4.1 - DSPP Operating Budget, FY76 - FY77 . . . . . . . . . . . . . . 49

-15-

POM=ON, HEALTH AND NUTRION STATUS

-9T-

-17-

MTible 1.1: S[IY aF PC['ACN SMff=CS EL)I SEE9 L SOOE

Total Crude Crue Tnfnt Nartiity ChidPxpulatin Birth Dth Murtality Life

Date Source (millions) Rate Rate Total Uroba Haral 1-4 years Hapectaucy

1971 IRS,Censu 4.3 36.5 16.0 147 - - 45 51

1970- Csaus and1975 latirxoud

Surveys 16.0 150 - - 27

1975- Projet ntr1976 at Petit-Goave

(rural) - - 107 18 52-3

1977 Haiti FertilitySurvey 5.0 37 14.5 124 197 103 47.5

I1978 NationalNutrition Survey - 147 119

1982 Cmsus, UNEstiutes 5.1 36 17.0 124 - - 31 48

1971 1980 2000

Urban Powulatimn (percit) 20.4% 27.5% 36.8X

Ppulation DenS3ty per sque kilbmer:Overall: 156 180Arable 1ad: 490-504 626

Amual Qxxwth Rate: 1.9X to 2.2%

Total Fertility Nate: 5.5 overall; 4.0 (Pbrt-au-Prince); 6.1 (rural areas)(1974-76)

Age structure: 5: 15.4%(estiutes for 1980) er 15: 405

Anmal OtMigrgtio At least 20,000 (0.); possibly ue than 40,000

Literacy: l0 to 20%

-18-

Table 1.2: PERCENTAGE DISTRIBUTION OF WOMEN EVER IN UNIONAGED 15-49 YEARS REPORTING KNOWLEDGE OF ACONTRACEPTIVE METHOD

Percent reporting knowledgeof Contraception

METHODS 1977 IFS 1983 CPS

1. Pill 75.4 94.42. IUD 51.8 53.63. Female Scientific Methods 30.0 43.44. Condom 52.7 90.85. Male Sterilization 14.1 17.76. Female Sterilization 37.9 36.17. Abortion 55.8 72.68. Douche 31.7 -9. Rhythm 55.9 20.2

10. Withdrawal 49.3 27.611. Abstention 41.8 15.112. Folkloric Methods 5.0 -13. Injectables - 53.614. Natural Family Planning - 15.1

Total Efficient Methods (I - 6) 82.1 -Total All Methods (1 - 12) 85.2

Sc'Lrce: Enquete haitienne sur la fecondite, 1977.Table 4.2.2.; Bicknell, W.J., et al, 1984, p.70.

-19-

Table 1.3: IlNFAiT MORTALITY RATES (PER 1000) FOR PORT-AU-PRINCE,RURAL AREAS IN HAII BY FIVE YEAR COHORT OF MALES- AlNDFEMALES FOR THE PERIOD 1956-1976, 1977

C o h o r t s

Area 1956-1960 1961-1965 1966-1970 1971-1975

Port-au-Prince 144 137 122 197

Ru-ral and Small Cities 124 142 143 103

Haiti 132 139 137 124

Source: Enque^te haitienne sur la fecondite 1977, Table 3.2.3.1

-20-

TAble 1.4: lSE CQ 52R1 (F KIUUIt GROWM RA IN RATlT

1970-2000

(per 1000 paplatiE)

Average Z AvmageCrue B2rth Crde !brt3lty Rate of Amhal GroWth

Period Rate Rate rat Cbmath Rate

1970-1975 37.01 16.20 4.86 L5.95 1.5951975-1980 36.78 14.48 4A2 17.88 1.788198D-1985 35.58 13.00 3.61 18.97 1.8971985-1990 33.51 11.52 329 18.70 1.8701990-1995 30.89 10.18 2.19 18.52 1.8521995-2000 28.29 9.09 2.01 17.10 l.no

Source: Haitian Iustitte of Statistics, 1980.

-21-

Table 1.5: CAUSES OF DEATH ALL AGES

H8pital Albert Schweitzer, 1979-1980 /a DSPP, 1979

(n = 806 (n = 1430)

Rank Diagnosis Percent Rank

1 Malnutrition 31Z2 Diarrheas 15% 13 Pneumonia 12Z 24 Tuberculosis 10Z 45 Meningitis 7Z 106 Septicemia 6Z n.a.7 Typhoid 4% 58 Tetanus 3Z 39 Prma-ture 3% n.a.

10 Malaria 2% 711 Congenial (newborn) 2Z n.a.12 Respiratory Distress (newborn) 1Z n.a.13 Post Partum 1% n.a.14 Heasles 1Z 12

/a Multiple diagnoses are coded at BHpital Albert Schweitzer.

-22-

Table 1.6: Cf1E CF =M, 1B AMMpital Albert Scweitzer, 190 (a

Infats Children Cbildrei Adlts Adults0-1 m3utb 1-4 years 5-14 years 15-44 years 45+

n=247 (Z) n = 249 (Z) I u 104 O I u=116 (Z) I nl9D (Z)I I . I

Diarrlm (22)1 !13Mutrition (71)1 N hJtitimn (35)1 TB (32)1 TB (19)Pum=ia (15)1 Diarbea (24)1 Typi id (12)1 ITypboid (10)1 C r (16)Septicemia (15)1 Pnemoia (19)1 Pamania (9) I Post partum (8) 1 Cirrhosis (13)Malzmtritim- (14)1t B (6) 1 TB (9) I alaria (6) 1C M (11)Manimitis (13)] }mengitis (5) 1 aaria (7) I *nits (3) 1 Coestivep e ture (9) 1 Typboid (3) 1 Diarrbea (6) 1 1 HEbatTetarqis (6) 1 liesles (2) I I I Failure (9)Co%enial (6) 1 Septicemia (2) 1 I I !ningitis (6)Respiratory ITetau Te l)a I

Distress (4)1 1 I IPertussis (3) 1 ITB (2)1 1 I I

La Mltiple diaposes are recorded at apit;al Albert Scimeitrar.

-23-

Table 1.7: EHAM: PRElECE CF I)E RN IfhIf I BY E=Qq 1978

Deg de inutm.ritiml

3e 2e ler Noxmal

B ic sggecgradque 60,0% 60,0-74,9 75,0-89,9 90,0+ Total

Nord-ouest 3,0% 22,8% 48,M 25,4% 100,0% ( 891)NDrd 5,7% 28.5Z 46;!Z 19,67% 100,0% ( 892)Arti-buite 2.5% 28,3X 45,4% 23,7% 100,0% C 889)Ouest 2,7Z 23,4% 47,2% 26,& 100,0% ( 895)Sud 3,6Z 25,9Z 46,0% 24,5% 100,0% ( 893)F4mntila

R Ptstif rural 3,5% 26,0Z 46,4Z 24,1% 100,0% (4A60)

Port-mt-Prince 1. 13,1% 43,& 41,7% 100,0% ( 893)Fb1tilln

M=atif lnatiXml 3,2% 24,1% 46,0Z 26,8Z 100,0% (5353)

Qrwe sp6cial - 8,% 15,1Z 84,4Z 100,0% C 730)

Souxce: .>quke natioiale sur 1"E= mutritim1 - Haiti 1978-esm de NRtr.t ic - DSPPIA?JCDC

-24-

Table 1.8: KWAT1VE WN)ICATO)S CIF NFVATIMI, FAIE IIIIDEI~M SrAi - nArn AN C 9Ms

~DniicenNaiti Republic Jamica Halatui

1. Goss Naticmal Thi (US$)per capita, 1983 32D 1,380 1,300 210

2. ptxatim. 1982 (tbousands) 5,201 5,744 2,246 6,4523. Percentage Urban. 1982 26 53 48 10

Fertility

4. Crmde Birth Rate, 1982 32 34 27 565. Total. Fertiaity Rate, 1982 4.6 4.2 3.4 7.86, Z wmnusin Ct; I"e, 19al 5 42 55 -

3DtaitV

7. CreDeathREite, 1982 13 8 6 238. TIfaut Hortality Rate, 1982

(agedim*del) 110 65 10 1379. Life epctaxy at birth,1982 54 62 13 44

-elth and Other Services

10. Umet n forlw/high Z 13/30 12121 21/25 -

U1. Perscos per physician (1980) 8,20 2,320 2,830 40,95012. brolbxt rate, prim", 1982 69 109 99 *213. hrolbwit rate, secoilaxy, 1981 13 41 58 4

Sources: World D3vent Beport 1984F and Word Bamk Ais 1985

-25-

Figure 1.1: PERCENT OF CHILDREN 3 TO 59 MONTHS WITHSECOND OR THIED DEGREE MAILUTRITION

45 IProjet Intfgr1975-1976 la

co 40 1.

*4,'4 I> 351 p' National

c |,- _ DNutrition Survey /c

o 30I - - Projet Inttrgr30 1~ .. *' ' _ ~<$> *; i; _s_4t_ :s 1977-1978 lb

.c I , -.o251

4 I~20

3 ' w,I

,~~~~~~~~~~~~~~~I If;

A 10 Y;

0 1054

~15 'dll

3 5 12 24 36 38 60

Age in Months

Sources:/La Division dCRygie'ne familiale (1979). Pr&valence de la nalnutrition

... au debut de 1'etude, p. 114./b Division dCRygiene failiale (1979). Pre'valence de la malnutrition

... a la fin de 'etude, p. 115/c Baureau of Nutrition (1979). Table 7, Pe-rcentage distribution of preschool

childreu by Gomez classes and age: Haiti 1978.

-26-

2a -10"; I evo;z- 'g7 /!w)Io /'

-27-

SECTOR PERFORMACE

\\

i i

-29-

T3b1e 3.1: DiS l IF MATAI3 /AUTJI ja AM 1ifPMMI=AL OFEfl /b Er (2MAFC L(N, 198D

1198 /a 1 D i I h Citers Bospita sL vith BEdsI I I FacilitiesDistrict/ EFstimted only Offerag

RogiG1 Pqulaticn I D9P ixced Privatel DMP |mxd I MP Priate [Total m I EPIE

NaLioa lTotal 5,500,000 146 34 115 41 23 25 19 403 83 119South egimo 1,120,000 39 17 17 21 2 5 1 93 7 39NIrth egion 755,000 28 7 23 7 4 3 1 73 22 33Pbrt-de-Paix 305,000 19 4 14 1 1 2 1 42 13 7St. Hrc 400,000 6 - 9 - - 6 2 23 13 4Qmasives 305,000 12 1 4 - 1 1 1 20 2 3Rincxe 275,000 12 - 7 2 - 1 - 22 3 3Belladere 290,000 3 - 2 - 1 1 - 7 - 5Jaemel 290,000 19 - 2 - - 1 - 22 2 2Petit-Goave 325,000 6 - 4 2 2 1 - 15 2 5West 390,000 IC IC IC IC Ic IC /c /c 4 10MetzoArma 985,000 11 c 5 33 8 12 4 13 86 11 9

Source: Searzaul Report "ACtiV2tes Of l(/P"Evalation and Reerch Section, IEF, DPs (October 1980.

La Is&Th estimate;b Evaluaticn and Reseerch Sectiom, ElF, DSPP 1981Ic West and Itrn cobined

-30-

Table 3.2: EPEDflmn (N Dcm Y HEATR V1CAT DSICT IEVEL, FYW8'

District MY78 Eqmpiditures - in Il$ Per Capita - in Us$

Belladere $192,880 0.90Cap BLitien 394,520 0.38Cayes 385,540 0.62Gaives 164,250 0.42RHinbe 159,100 0.10Ja_el 236,780 0.55Jeremie 179,740 0.50Petit-Goave 294,380 0.50Port-au-Prince 2,201,060 3.36Port-de-Paix 179,740 0.66St. Irc 262,840 0.62

see $0.92

* ludes costs of aminirstratim, training, cetral DSP Staff,the SNEM and the IUF.

Source: Developed frc BLx%get de Fc 0meent, Defay Report,and Facility Survey of the Statistics Sectim, ad AMDproject mterials.

-31-

Table 3.3: DISiRJJ1UIil Ci UFAT PEB9Sat f CT AM 1E 5 IN 1982

I NimD I IRA15S I OET I SD I 7MLI I _I I I

Persiie I Fist. Necessi Exist. Necessi Exist. Recess Exist. Necs Eit. Necess.

Nedecm 51 33 71 91 479 54 84 655 208Dentiste 9 4 17 24 42 12 14 so 42Tnfimier 68 25 64 94 295 71 91 498 210kAudliiare 228 40 236 336 437 392 405 1,293 781Tech. Lab. 34 15 19 30 89 13 19 155 64Off. Sanit. 37 21 57 70 127 40 52 261 143Statistdcim 11 4 1 6 40 4 4 56 14Agent de Snte 130 40 103 203 231 164 550 628 793Ies Autres 641 30 581 1,458 393 633 3,273 663

Total 1,209 212 1,149 854 3,198 0 1,343 1,852 6,899 2,918

Peed. 2 2 1 5 6 0 0 3 9 10a3ir. 4 2 3 5 4 0 2 4 13 11med. Int. 4 2 2 5 6 1 2 3 14 11abgya. 7 1 2 5 4 1 3 4 16 U

nrl 1 3 2 5 3 2 2 3 8 11OArtLx3pe. 1 2 5 0 2 2 2 3 II2Auestbes. 1 3 1 5 0 2 3 5 5 15

Total 20 15 U 35 23 6 14 24 68 80

Smurce: finistire de la S9=t6 pubWique et de la populatimn, "Evazuaticmdes Prormmoes de sante," p. 30.

-32-

Table 3.4: SCQE MHR UEIA3 PERSIElAM SE FnflV-ff, 1981

lTkicatr or aGna r 1981

Hw-th sector labor force 10,000 /a

TAl public setor labor force 29,000

Total Eaitian labor force (tbousands) 2,400

Gross Dstic P r c, $ nilim $1,49

Total public sector e nitures curand developz0t bu%;ets, $ milliI $340

P-ublic sector bealth ezpeoditures, artand deelopnet bu%ets, $ millins $40

Avege GP per mer, dollars per $624

A-erW gomt wr I - ezpsiture pergoveromwt ker, dollars per m $11,724

- bealth exuxitmes pergoverzu.nt health woker, dollars per 4,000

sa N.ier of payroll cecks issued, 10,000, eceed*muer of employees.

-33-

Table 3.5: AI, SAlARSm C CEVI 5WU E T, 1978.

Meges & Salaries Numb~er of Average SalaryAk4iinistraui 0Os of Gt.ides lnployees in Girdes

FOucation 28,929 6,624 /a 4,367elth 28,242 5,518 5,118

Fcondic Services 39,864 5,181 7,694Ces1 Pzblic Service 40,576 3,241 12,52)Cca.mity and Social Services 4,213 695 6,062Witht ParetfDlio 392 10 39,18D

Total 142,218 21,269 6,687

La Estim baued c budget; figure give by Miistry is 8,100 aox my sbx.plamed ina in persomel 'bich, aX the otber hud, aSppreat1y is notyet reflected in the budgeted salaries.

Source: I= Report No. 2165-HL, Curret econc position aDd prospecu ofHaiti, Volme II, Table 5.6, W¢rld Bak, Vehigtcm, D.C., Dec. 22, 1978.

-34-

Table 3.6: AVERA n MTNSW UtTMTZATMlBY PVIE - 1979

Number ofNiuber of Nate of Emstinztel

District __ F_ CDcytact/ 11

Pbrt-au-Price 33 211,137 27cap ritien 55 382,355 29Port-de-Paix 18 57,602 13Gwaives 7 30,052 18

4 12,916 13St. Mbrc 6 54,809 38Helladres 4 29,304 31J-am1 9 11,157 5Petit GQae 6 66,031 46les Cayes 32 218,278 28

Jerenie 22 128,278 24

Tot&]l 196 1,202,189 26

efipres ,e calalaed by dividig the ors igcontacts by the mer of dispensaries and the estimated mutr ofvodzng days in ce year, 240.

-35-

Table 3.7: DISM] RINT F EvisIS AM= G 1EGIfSlDISIC1S - 1979

Numter of Number of VisitsEgicaKIuDistrict Populatimo 1/ Visits ZI per Persoa

North 758,461 521,551 .69Port-de-Paixz 232,531 116,786 .90St. MIwcz 359,791 173,044 .48South 1,098,650 424,464 .39Petit Goave 293,275 112,416 .38Port-au-Prince 1,971,907 654,055 33BeSL-aieres 169,256 53,580 .32GcmLives 320D288 83,888 26Hinche 142,307 36,598 26Jacuel 310,655 32,163 .10

Total 5,657,i.21 2,208,545 .39

tJ TAikn froa tiBletin de Statistiques et dEpidnmioIqgie,&ree 1980. September 1981 wbich cited "I.R.S.. .1978."

Estimated umd of visits taking into acc.mnt estimated rqxxrtiurates, based am data fron Table 3-1 in Rappert Air-l dhActivites

pitaliArc '79. See page for calculatims.

-36-

Table 3.8: PEREN DISIRINlM aF IITIf aiNrACrSEr TI aF TTEATlR E1fll - 1979

FamilyType of Fclity Adult Pedtc Prenatal imta1 Plming Total

Hspital 27.5 31.4 27.8 28.9 46.1 29.3Centre de sante 19.1 31X5 26.9 70.1 36.3 24.9D _spe2sary 53.5 37.1 45.4 1.0 21.5 45.9

Total 100.1 100.0 100.1 100.0 99.9 100.1Sue ostyTa ==m=

Sorc: DPP costs stxl. Ttattls soy not add to 100 percesl due to rcuing errr.

-37-

Table 3.9: PE1R DIPRIBfCa P 4ATM CllAC1if CAME= OF ValArM, 1979

Fmlytype of Facility MAdlts Peiatric Preatal Dta1 Plnm!ig Total

Ebspital 52.2 26.9 12.3 2.2 6.3 99.9Centre de sant6 42.7 31.8 14.0 6.3 5.2 100.0Disp:iSU 64.9 20.3 12.8 - 1.9 99.9

Total 55.7 25.1 13.0 2.2 4.0 100.0ue = = ---

:uce 1;e costs stud.

-38-

Table 3.10: MPARTA CASES PEEL YlR AND SLED -P1TVlYS RAMI,1962-1977, 1984

year Nmber of Cases Slide Positivity Rate

1962 4,033 3.61963 6,340 1.671964 19,169 4.041965 10,304 1.371966 8,378 0.371967 4,871 0.361968 2,562 01969 5,002 0.731970 10,366 3.01971 11.347 4.21972 25,961 8.31973 22,858 7.41974 25,441 7.11975 24,772 7.11976 15,087 4.01977 27,679 6.91978 na. 15.01979 48,000 n.a.1984 250,000 E n,a.

n.a. - t avilable

Sburce: 1962-77, SNEM 1978, 1979, 1984, AID estfimtes

-39-

Fisure 3.1: SUMEIMARY OF DSPP STRUCTURE AFTERSEPTEMI 1983, RESTRUCTURING

DSPPSMinister l_Secretary of State Director General AGAPCO SNEM

nQi rec ors I

DSPP s xt_REGIONAL OFFICES REGIONAL OFFICES

L (North, South, ) _ (North, South, (Transversal. West) Transveal West

PYOs andMissionaryHealth Facilities

Mixte Facilities. -SDiPP Faci ities:-agional Hospital

District 1Hositals

Health Jenters(with and without bedsl

Oisoensarips,

As Community Agents Heal'tSAgents DH'/ENn(urban) (rural) Special Volunteers

Projectvolunteers

-40-

Figure 3.2: DISTRIBUTION OF HEALTH MANPOERE INTHE HEALTH INFRASTRUCTURE PYRAMID

Hu )M ERSI )/OSPITL \)

s ) With doctor, nursesRegional ) auxiliary nurses andHospital ) community health nurses

District )Hospital )

Health Center )without or with beds )

w \ ) With one (1) or two (2)DISPENSARY ) trained auxiliary nurses

* \ ) With health agents andCOmMUNITY t) :raditional birth attendants

-41-

FINANCING POPULATION, HEALTH AND NUTRITION

It

h11

I~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ .,;L

~ lii Ut aSgSu ii ii .3 g|wt[t>;iii ttt

-44-

Mable 4.2: PNUKCI J D6PP BUDG DE E(1,OOOS GDImPS)

Fiscal Year 79/80 80/81 81/82 82183 83/84 84/85 85/86 86/87

Carreot DSPP Dwdgetde Fbection.i_..t 61,878 58,783 58,783 58,783 58,783 58,783 58,783 58,783

Mm Recurring Costicati.os 704 3,755 6,671 10,703 12,596 15,048 16,747

Assmption of Baoe SalariesNow Paid frau PC.480 1,333 2,667 4,000 4,000 4,000

Increased GOH Funingof SEX 775 1,775 2,775 3,775 4,775 5,775

Inceased MPP Fmdgof DF 1,434 1,714 2,184 2,304 2,30C 2,304

Recurring Covt Tuplicatimuof iMiS NHtritimo 345 585 615 615 615 615

,.relat Helth CEiterCwtructia by RED 462 1,974 3,486 3,486 3,486 3,486

P med PRitmreCcxstrnctici by RiD 1,000 2,000 3,000 4,000 5,000

Recurring Salaris andSupplies at Cite SRIoeCbildren's Clinic 400 400 400 400 400 40D

Total . . . . . . . . . . 61,878 59,407 65,954 74,235 83,613 88,959 93,411 96,110Actual Bodgets 61,878 58,783 58,783

&xget Sbortfan 704. 7,171

Requixed Pbture Increase 15,452 9,378 5,346 4,452 2,699Z Increeme 26.3 12.6 6.4 5.0 2.9

verage Caupoudled Rate of Increase - 10.3%

lNte: fajDr Asszptioas:1. Nb inflation; 2. Nb Increase in 5alaxy Scale; 3. Mb Significant Qiange im Ratio ofSalaries to Otber Operating ODsts; 4. ND Ubfaceseen Developmeot Projects withREcxxring Co%ts.

-45-

Table 4.3: I6PP DM RTJ EEr FM FY81IN U.S. DauAs

Secti S$

14-01 Ceotral Mzdnistraticm 3,826,5714-02 Di4visim of Public Assistace 2,910,71714-03 Divisiom of Public ie and Prevenive Medicine 1,586,30214-04 Division of Caumty Meine 2,8002614-05 Divisim of Dology 88,20014-06 Blood Bank 7,92D14-07 Facuty of %I4icine and Ph 9nucy 200,99814-8 Faculty of Ocntol 64,18314-09 Simoe 0. D.vaLier National Schools of hrwsimg 171,04814-10 NasX Kline Pycbiic Cute 61,08014-11 Trnqpot Reppairs and lahm±ts e 358,14014-12 Speial Sevices 12,00014-13 Schol of Melical TecJmology 15,00014-14 Diisima of Medical Research 4,62014-15 Techical Services of the Sertary of State 61,62014-16 Division of Family Bygie 13,14014-17 Asylmr 193,68D

Total 12,375,500

Source: DMP Budget for 19OD-1981.

-46-

Table 4.4: ]EPP lVEEIl BNGEr EUR FYM(in llS Dollas)

Prgr Project umtee FuzsC$)

1. RgoalizAtinx of HEh Services 2,679,995a) Costuctig and Equiping

Health Esabs t,North and South 2,060,000

b) lleinf of DSPP 70,000c) POO (}ral potable water

and sanitation) 549,995

2. Maternal and hld alth d F adly Planing 4,332,047d) ME and Family Plmnm 3395,247e) EM and Nltritin Qeters 936,800

3. Ctrol of Iajor Fadanic Diseases 400,000f) Malara, TB Coutol 400,000

4. Stgge aginst & l.±ritin 232,92Dg) lpxovqo=et of Nutriticn 124,600b) Developing Food and %tgitim

Policy 89,320i) Nzaritiol Tedlology 19,000

5. Feinf o tt of Health Services 6,852,400j) Natimal Systen of lural Mlicine 4,264,000k) Str. itbeiiig Dep tawtof

Cdmiy mic i 77,000i) Cxtfiwnig Fuatiom for nurses 16,999a) m3at h in Urban Ccumities 660,000n) ln ewiwlSuor Of DM 1,815,400o) Bloo Ban 20,000

Total 14,497,362 14,497,362

Source: Ministry of Plan, Developzet Budget for Fiscal Year 1981.Table 11.2, p. 23.

-47-

Table 4.5: ClML BUM FM TM HFAUR SE 1R m FOR 1981-1986(in thousmds of U.S. Dollars)

Projert FM FM FM FM FY86 TOM

1.1 Ruiral Helth Delivuery Systenm)1.2 Mhinistrative System of DSP) 5,304 5,504 5,704 6,104 6,404 29,02D1.3 Hospital Care lrov ±n )

1.4& POCE (Rural Water) 1,777 1,699 1,699 1,674 1,699 8,5481.4B U11 S2itaticn 900 1,000 1,000 1,000 1,000 4,90D

1.5 Tnstitutional Support of D5PP 10,000 11,000 12,000 13,000 14,000 60,000

1.6 Taxzculosis 761 310 10 300 300 1,781

1.7 HBeath EBucation 200 300 300 300 300 1,400

2 eStianliYAtinn 2,180 2,000 2,000 2,000 2,000 10,180

3 "MOP 2,868 2,918 2,955 2,375 2,279 13,395

4.1 lIprovizg Nutritiomal Status 1,31) 815 731 679 697 4,2424.2 iWrld Food Py rg aa 713 713 713 713 713 3,565

5 StlE (Halaria, 7B) 2,200 3,500 3,500 3,000 2,500 14,700

Total 28,223 29,759 30,712 31,145 31,892 151,731

Source: DSP., Plan Qinquemnal 19U1-1986. Page 44.

-48-

Table 4.6: DONORS IN HEALTH 1980

(G million)

Donor Amount

USAID G 14.4 m.IDB 11.1WHO 10.4UNlDP 3. tKreditanstalt 0.1Other 0.3

Total 40.0

So e I=

Source: IBID CEKI, Table 1L-25

-49-

Figure 4.1: DSPP OPERATING BUDGET, Fm76 - FY87

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