What a Day!

Yesterday, the CEO of Direct Relief International, Thomas Tighe, arrived into Haiti with his 16 year-old son Travis. I don't know whether it was just good timing or kismet, or just fantastic (Plandrew-ing) but in the first five hours of his arrival, we had met with the Minister of Health for Haiti, Paul Farmer of Partners in Health, and the head of health services for USAID Haiti. Because his arrival coincided with a large meeting of ministry and health care officials who were discussing the interim plan for health care in Haiti, we were able to get them all down together at one time to discuss ways we can assist the country recover from the damaging health-related effects of the earthquake. They were all grateful to hear what we've done and we have plans to meet with the head of pharmaceutical services tomorrow to discuss what medicines are needed and how we can best communicate and deliver the products we are bringing into the country.
And to top it all off, Paul Farmer, who I've never met, recognized my name from a Huffington Post blog I wrote about Partners in Health. He said that although he never reads blogs because of all the bad information that circulates out there, he really thought my post on the long-term health services in Haiti had captured the nuances that many people miss. And to show his sincerity, he personally signed and sent me a copy of his new book.
It feels like Direct Relief is genuinely starting to get some traction in this country and people are beginning to take notice of who we are and what we're doing.

Getting Ahead in Haiti

A few days ago, my colleague and I were scheduled to drive up to Hospital Albert Schweitzer to assess their medical supply needs and determine what more we could supply them from our medical supply inventory. Unfortunately, as we soon found out, we wouldn’t be able to make the three hour drive to Deshapelles because our car was out of gas and our local staff member had been unable to purchase gasoline for pretty much the entire week before we arrived. When he was able to get fuel, it was only after waiting in line at the pumps from noon until 5:30pm because he didn’t want to risk purchasing it from the street vendors who often mix it with water. So unfortunately, we had to cancel the trip and turn it into a work-from-home day. We are now on constant alert for gas stations carrying fuel so we don’t get stuck again.

But a gas shortage in Haiti doesn’t just mean fewer cars on the streets. It means that houses, hospitals, schools, and businesses can’t run their generators to keep their lights on or the equipment running. Now that many hospitals in Port au Prince are working out of tents using generator-powered equipment, a fuel shortage can have devastating consequences.

And a gas shortage cripples businesses as well. The warehouse we rent as a storage and distribution site for medical supplies is actually in a factory where they process and bag clean drinking water and make huge blocks of ice so people can have cold drinks. A lot of people do not own ice makers, but even if they did, they would also need constant electricity for the units to function. So this business distributes bags of water and blocks of ice get via truck to local vendors who sell them on the streets. And a gas shortage means that they cannot make clean drinking water.

The barrier for entry for businesses in Haiti is extremely high, and this is a huge contributing factor for the high unemployment rate.Things we completely take for granted in the US are not so in Haiti. To open a business, you not only have to provide your own security, but you also have to ensure that you have your own constant fuel supply (or, rather, a reliable source electricity, like solar.) The entrepreneur-owner of this water and ice factory spent eight years lining up all the necessary pieces, and when he finally did open, he had 10,000 people come in to apply for 500 jobs.

People want to work; they just don’t have the opportunity to. A fuel shortage affects every step in the commercial processes of manufacturing, distribution, and sales. And a fuel shortage doesn’t inspire much confidence for entrepreneurs here, who, like everywhere else drive economic activity.

Haitian Hospitals in a Catch-22

Since the devastating earthquake on January 12th, hospital services in Haiti have been provided to patients for free. No matter what your status or ability to pay, for three months after the earthquake you could feel certain that you could see a doctor and (hopefully acquire medications) for free. This was a fantastic service and was a great idea because it enabled the poor to have access to the health care services that they often go without.
However, the free service in many facilities has now ended because these hospitals have only been guaranteed reimbursement for their services until April 12th. Many hospitals are now struggling with what to do next.
If they begin charging people to see the doctor, the majority of Haitian people will not be able to afford it. Thus, the follow-up treatment that is so essential for people who are newly handicapped and people with chronic conditions will go untreated. However, if they do not charge, many hospitals will be forced to shut their doors. In fact, one of the premier hospitals in the country, Hospital Sacre Coeur (CDTI), recently shut its doors because they sustained a great deal of damage to the hospital building and had to spend so much of their own money treating patients for free while (still) waiting for the reimbursement monies. Like any other business, a hospital must have income to finance their operations. Even the non-profit hospitals, of which there are many fantastic ones in Haiti, have to generate income somehow to pay the staff and the buy the diesel for the generator.
However, there is another devastating aspect of this story. As we all know, there was an incredible number of doctors and nurses who came to Haiti in the aftermath of the quake to assist in these facilities and the work they have done in the past three months has saved countless lives. It has been easy for these medical personnel to work in any of the hospitals and clinics in the area because everyone was providing services for free. These overseas medical personnel don’t want to make the patients pay for services they are providing out of the goodness of their hearts. However, now that some hospitals are beginning to charge again, these doctors and nurses are avoiding those facilities that are forced to take fees. These hospitals are now losing the expertise of the overseas medical personnel who do not want to work in a place that is charging the patients for the work they are doing for free.
Unfortunately there is no easy solution to this problem. The health care system in Haiti has been set up as a fee-for-service model. To change that now would take a lot of money that Haiti does not currently have. Unfortunately, if it doesn’t change, the hospitals will have to begin charging patients, overseas medical personnel will not want to work in these facilities, and the Haitian people will suffer as a result.
An efficient, self-sustaining and self-financing system for health care is very attractive but also very hard to achieve. Even the United States, the richest country in the history of the world, is trying to figure out how to do it. Significant resources have been donated for Haiti in recognition of the immense scale of loss and much of these resources have been used in part to subsidize the most basic goods and services (including health care) that people need but simply do not have the ability to pay for. Pulling this subsidy out now, three months after the worst disaster in the Western Hemisphere seems too abrupt. If there was a gradual lessening, rather than a complete elimination of the subsidy, perhaps there would be time for the market forces to kick in without kicking out all the people who lost everything.