To illustrate the role hospital-level health services play within global health programs, we will use the example of one such project in Haiti that one of us (DW) has been extensively involved in while practicing hospital medicine part time in the United States.
Haiti is Latin America’s oldest independent nation, born of a slave revolt that began in 1791. Over 95% of its population is descended from African slaves, and Haiti’s history has been characterized by ongoing political strife. Haiti is the most impoverished nation in the Western Hemisphere, with an estimated 80% of the population living on less than US $2 per day. There are profound inadequacies in health care, education, and housing. Haiti has the highest infant, maternal, and child mortality in the Western Hemisphere, and life expectancy hovers at 52 years of age.
Partners In Health (PIH), a small nongovernmental organization based in Boston, and its partner organization, Zanmi Lasante (ZL), based in Haiti, have been working in the Central Plateau of Haiti for over two decades. This region is home to 550,000 people, most of them living in villages and in small towns, with poor access to potable water, paved roads, electricity, and health care.
In 2002 GFATM awarded Haiti a multiyear grant to expand HIV and TB services. PIH, a recipient of a portion of the grant, was given a mandate by the Haitian Ministry of Health (MOH) to carry out the expansion in the Central Plateau. The first “expansion” site was the small town of Lascahobas, an agricultural market center without industry or tourism that is located 2 hours from the border of the Dominican Republic. At that time, the only existing health infrastructure for the catchment area of 60,000 was a small ambulatory clinic run by the MOH. The staff included one doctor, one nurse, and five nurse’s aides. There was no capability for hospitalization, care was fee-for-service, there were few medications available, and electricity and running water were unreliable. The clinic saw 12 to 20 patients per day. The nearest district-level hospital was an 8-hour trip on the back of a donkey, the primary mode of transportation.
Rather than implement a “vertical” system, solely providing care for the targeted diseases of HIV and TB, PIH and ZL sought to strengthen primary health care and hospital-based care by integrating TB and HIV services within a “basic minimum package” of services, which included the following:
Training and capacity building for community-based care of chronic disease (HIV, TB, heart failure, diabetes, etc)
Community-based care delivered by village health workers
Construction of an inpatient facility for medicine and pediatrics
Electricity and running water available at all times
A formulary of essential medications for inpatients and outpatients
Plain film x-ray capacity
MOH staff along with PIH-trained staff
Program capacity for diagnosis and care of TB, HIV, and sexually transmitted infections
Program capacity for prenatal care and women’s health
A maternity ward
A rapid referral system was established for cases that could not be dealt with at the clinic (eg, surgical emergencies, complications of labor). The referral hospital (a district-level hospital) and the clinic were connected via satellite Internet connection (at the time, there was no cellular telephone access in the Central Plateau). Messages sent were received in real time by on-call surgical teams, and the clinic provided transportation of patients.
In addition to the “basic minimum package,” large-scale efforts were undertaken to increase vaccination among children and infants, as well as creating access to potable water for villages in the catchment area. Mobile clinics were conducted for communities that were located at the periphery of the catchment area (and often on mountainous terrain).
The results were as dramatic as they were rapid. Patient visits went from 20 to 150 per day in less than 3 months and plateaued at 250 to 350 after approximately 12 months. Rates of vaccination, diagnoses of HIV and TB, and prenatal visits increased dramatically. The 15-bed inpatient facility was at 100% capacity daily. It soon became apparent that, despite the rehabilitated infrastructure, the amount of patients seen was too large for the space available. After several years, additional funding was procured for the construction of a new hospital that would be owned by the Haitian MOH. Careful attention was paid to organization of patient flow, infection control in the wards and large waiting areas, inpatient capacity, and expanded laboratory capacity during the design phase. Once all medical and pediatric services were moved to the new hospital, the old clinic was renovated to create a hospital dedicated solely to women’s health (see Figures e1-2 and e1-3).
The new hospital near Lascahobas (in Lacolline).
The new hospital waiting room.
Today the acute care hospital has a staff of 12 physicians and residents who see approximately 400 patients daily. Inpatient capacity, which now exceeds 60 beds, has an average census of 100%. At the women’s health hospital, the number of deliveries has tripled, prenatal visits have doubled, and average daily patient encounters exceed 160 per day. A small operating room for emergency cesarean sections was built and is fully supplied. Cellular phone service has been installed in the Central Plateau, which has facilitated an already rapid referral system to the nearest district-level hospital.
PIH and ZL’s experience in Haiti has demonstrated that “vertical” funding for HIV-related public health programs can strengthen primary health care and hospital-level services when used wisely. Although the primary funding for the clinic in Lascahobas was to expand AIDS care and prevention, by using this money strategically, PIH and ZL were able to strengthen the overall health system in Lascahobas, including primary health care and access to hospital-level care, in addition to delivering improved HIV care.
Such examples illustrate what we could achieve with many of the large investments being made today in global health. For instance, the reauthorization of the US President’s Emergency Plan for AIDS Relief (PEPFAR II) will invest US $48 billion over the next 5 years to treat HIV/AIDS, TB, and malaria worldwide. This money will also be increasingly used to build sustainable, local capacity and, if used wisely, will improve overall health care service delivery in the nations in which PEPFAR operates.