Haiti, located in the Latin America and Caribbean (LAC) region, has a human development index of 0.44, ranking 112 out of 157 countries (WDI, 2018). This means that a child born in Haiti today will be 45 percent as productive when she grows up as she could be if she enjoyed complete education and full health. More needs to be done in the health sector so that a child born in 2018 in Haiti has the capacity to reach her full potential by the time she enters the labor force. This dissertation investigates reasons behind the poor performance of Haiti’s health sector, which impedes improvements in its human capital and providing Universal Health Coverage (UHC). UHC is a key part of the Sustainable Development Goals (SDG) and is monitored by the UHC service index coverage and rate of catastrophic health expenditure (CHE).
The first paper assesses inequalities in health service utilization and out-of-pocket payment (OOPP) for health using the 2012 and 2013 household surveys. The rate of CHE increased from 9.43% in 2012 to 11.54% in 2013, most particularly for the poorest (from 11.62% in 2012 to 18.20% in 2013), which also coincides with a sharp decrease in external funding. Econometric analysis demonstrates that wealth quintiles had a stronger influence on the incidence of CHE in 2013 than in 2012, and that community outreach was pro-poor and protected households against CHE, while medicines were the key drivers of OOPP.
The second paper examines the role of health insurance on health service utilization and CHE rate using the 2013 household survey. The main finding is that households with health insurance are associated with higher health service utilization, but this also contributes to an increase in the CHE rate and undermines financial protection.
The third paper assesses the effect of community outreach activities on the number of institutional visits, using the 2014 Service Provision Assessment and routine information management data from 2016 to 2018. Main findings are that community productivity leads to better health facility production up to a point. But there is turning point by which having more community staff has a diminishing return for health facility production: nurses working at the community level will contribute to community productivity, but may spend less time at the facility, hence hindering the number of institutional visits.
As Haiti is about to review its National Health Strategy Plan, findings from the three papers suggest that Haiti may explore scaling up community outreach as a pro-poor policy. Additionally, better guidelines are needed to clarify the role of community and institutional staff with respect to community outreach to ensure facility production and service coverage is not affected. The Government of Haiti may also consider the feasibility of subsidizing the poorest to get health insurance to address adverse selection and poor financial protection. However, this requires reviewing the package of health services covered by the health insurance premium and making sure the latter addresses populations’ needs, e.g., medicines, which is the main driver of OOPP in Haiti.