Nursing Outlook
Volume 60, Issue 1 , Pages 16-20, January 2012

Nursing and nursing education in Haiti

  • Richard M. Garfield, RN, DrPH

      Affiliations

    • Columbia University School of Nursing, New York, NY
    • Mailman School of Public Health, Columbia University, New York, NY
    • Corresponding Author InformationCorresponding author: Dr. Richard M. Garfield, RN, DrPH, Columbia University School of Nursing, 617 West 168th Street, New York, NY 10032.
    • ,
  • Elizabeth Berryman, MSc, RN, RGN

      Affiliations

    • Merlin, London, UK

Received 1 December 2010; received in revised form 11 March 2011; accepted 26 March 2011. published online 11 July 2011.

Article Outline

Abstract 

Haiti has long had the largest proportion of people living in poverty and the highest mortality level of any country in the Americas. On January 12, 2010, the most powerful earthquake to hit Haiti in 200 years struck. Before the earthquake, half of all Haitians lacked any access to modern medical care services. Health care professionals in Haiti number around one-fourth of the world average and about one-tenth the ratio present in North America. The establishment of new primary care services in a country where half of the people had no access to modern health care prior to the earthquake requires advanced practice roles for nurses and midwives. With a high burden of infectious, parasitic, and nutritional conditions, Haiti especially needs mid-level community health workers and nurses who can train and supervise them for public health programs. As in many other developing countries, organized nursing lacks many of the management and planning skills needed to move its agenda forward. The public schools prepare 3-year diploma graduates. These programs have upgraded the curriculum little in decades and have mainly trained for hospital service. Primary care, public health program management, and patient education had often not been stressed. Specializations in midwifery and HIV care exist, while only informal programs of specialization exist in administration, surgery, and pediatrics. An advanced practice role, nonetheless, is not yet well established. Nursing has much to contribute to the recovery of Haiti and the revitalization if its health system. Professional nurses are needed in clinics and hospitals throughout the country to care for patients, including thousands in need of rehabilitation and mental health services. Haitian nursing colleagues in North America have key roles in strengthening their profession. Ways of supporting our Haitian colleagues are detailed.

Keywords: Disaster, nursing education, earthquake, emergency preparedness, international development, educational modernization, international solidarity, volunteers

 

On January 12, 2010, the most powerful earthquake to hit Haiti in 200 years struck. The capital Port-au-Prince suffered substantial damage, as did a number of major/nearby towns. It is estimated that more than 250 000 homes were leveled, at least 200 000 people died, 300 000 were injured, and 1.3 million people were displaced to temporary shelters. Within the disaster zone, 30 out of 49 hospitals were destroyed or damaged, as were the majority of health centers. Thirteen hundred educational institutions were partially or fully destroyed. Public buildings including Parliament, courts of law, the Ministry of Health and Population (MSPP), and the presidential palace were destroyed. Over 600 000 people moved out of the Port au Prince area, creating increased demand on services and facilities throughout the country. While the needs for recovery in Haiti are great, the opportunities presented by the outpouring of international support suggest that Haiti can make great strides forward from the poor health status and health system in place prior to the earthquake. Leveraging this, international commitment and strengthening nursing education and practice are crucial to Haiti’s recovery and health system development.

Policy Implications


Public Policy

Health Sector strategies should focus on high-impact, low cost interventions targeting maternal and infant health.

Regional training facilities for primary and community care should be developed and led by medical and nursing educators.

Uniform standards should be set for community health workers, professional nursing, and advanced practice.

Educational Policy

Haitian schools of nursing should focus skill development for expanded practice roles for nursing.

The redevelopment of midwifery could fill a critical role in rural areas and assist in the expansion of advanced nursing practice.

Pre-service accreditation and terminal credentialing are needed to upgrade schools of nursing.

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Background 

Haiti has long had the largest proportion of people living in poverty and the highest mortality level of any country in the Americas. Unique among the countries of the Americas during the last 2 decades is the fact that, while income grew rapidly through most of the world, per capita income in Haiti declined by half. The crude death rate among Haitians, estimated in 2004 at 1611 per 100 000 population, is about 30% higher than the mean of the next 2 poorest countries in Latin America (Nicaragua and Bolivia) and neighboring Dominican Republic.1 Life expectancy at birth in Haiti is 50 years; this is 27 years less than the mean of these 3 comparison countries.2

Haiti has been plagued by unstable, weak, or exploitative governments and repeated ostracization by the major powers for much of its 206 years as a nation. High fertility has left Haiti with a very high population density throughout the country, even in rural areas.3 Peasant agriculture has stripped the land of much of its productivity, and deforestation has created an environmental crisis. Together, these threats greatly exacerbate the impact of the many natural disasters to occur in the country.

The January earthquake led to unprecedented engagement by the international community and opportunities for reconstruction with large-scale international support expected to last 8–10 years.4 Haiti now has more funds available, and for a longer period of time, than even the countries affected by the tsunami in 2004. The governments of Cuba and the United States have already provided extensive support, and substantial pledges from Brazil, Canada, France, and Spain have been made. Most notable among this support is the presence in Haiti of thousands of medical and nursing volunteers from the United States and other countries. Perhaps as many as 1000 nurses from throughout the United States have served as volunteers in clinics, hospitals, and displacement camps since January. Hundreds of nurses continue to return to Haiti during short vacations, as long-term volunteers, or as staff for international humanitarian agencies. Haiti has never before had this level of international expertise and assistance on loan for medium and long-term reconstruction and development. How this opportunity will be used is largely still to be determined.

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Current Health Care System in Haiti 

Before the earthquake, half of all Haitians lacked any access to modern medical care services.5 Health care professionals in Haiti number around 5400, or about 2.8 health workers per 1000 inhabitants. This includes one physician and 1.8 nurses per 10 000 population.6 This is one-fourth of the world average and about one-tenth the ratio present in North America. Haiti’s 3 medical schools and 5 leading nursing schools graduate about 200 nurses and 300 physicians per year. About half of them leave the country within 5 years due to poor working conditions and limited employment opportunities. It is believed that there are more Haitian physicians and nurses in the United States than in Haiti. During the last 5 years, the largest health assistance has come from the President’s Emergency Plan for AIDS Relief (PEPFAR), and from the Cuban medical brigade, with 1000 staff in Haiti and training 200 more physicians a year in Cuba.7 Haiti’s health system delivers services through a mixing of public sector (35% of service provided), private sector (33%), and a mix of MSPP personnel working with private institutions, non-governmental organizations, or religious organizations (32%). In practice, most of this system has functioned poorly. Salaries often were not paid by the government, and user fees from patients were required for even the most basic of care in many public sector institutions. The income of most Haitians is less than 1.25 American dollars a day, thus user fees decreased utilization of public institutions and did not provide sufficient funds to maintain even basic health services. More than 600 charitable non-governmental organizations are the major providers of health services. These charities receive little direction from the MSPP.

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Health Goals and Strategy 

Emergency response focused predominantly on patient demand in hospitals and clinics. Funding and personnel available to Haiti in post-emergency reconstruction of the health system will be effective only if services are well-targeted on low-cost, high impact interventions that achieve wide geographic coverage and focus on priority conditions and health system support. Major goals should include reducing maternal and infant deaths through primary medical care service interventions and emergency obstetric care, community-based prevention and control of infectious diseases, primary-care-based HIV/AIDS and TB treatment, and physical and mental rehabilitation. The core of the government’s health sector strategy is geographic decentralization and revitalization of rural communities. This is designed to focus on the establishment of 54 Unites Communales de Sante (UCS, Commune Health Units). The UCS should focus on high-impact, low-cost interventions targeting maternal and infant health.

This strategy will require profound changes in nursing education and practice to serve the needs of the country in post-earthquake reconstruction of the health system. It will require a large cadre of locally trained midlevel community health workers, professional nurses to train and supervise them and manage health centers, and advanced practice nurses and midwives as providers for the network of care centers, public or non-governmental organization (NGO)-run, throughout the country. To create and manage such a training system, a network of regional training facilities led by medical and nursing educators connected to the MSPP is necessary.

The biggest challenges confronting Haiti today are the difficulties faced by a government with little experience in managing large reconstruction funds and coordinating hundreds of private voluntary agencies. Most of the public health facilities in Haiti are, in fact, coordinated and staffed by international charitable organizations that receive little direction from the MSPP. Haiti lacks entry and midlevel health workers needed to carry out such an ambitious community health agenda as well as the supervision, continuing education, and normative national programs.

Incorporating the 600 charitable NGOs obligates the Ministry of Health to provide leadership and coordination to set uniform standards for health worker levels and payment.8 The government must also specify job roles and train thousands of auxiliary health workers for basic sanitation and disease control programs.9 Medical and nursing schools must expand and revise their training content and methods to prepare health professionals to be able to lead auxiliaries in primary care clinics and hospitals. There has not been a program to train such personnel for several decades and NGOs have trained their own. All of these training needs require close consultation with the MSPP so skills fit better with the disease burden and health system organization.

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Nursing and Nursing Education 

Of any country in the Americas, Haiti is one with the fewest number of nurses.10 It is estimated there are approximately 1400 qualified nurses in Haiti; about 1000 nurses and 1500 auxiliaries are employed by the MSPP, and perhaps 400 more work in the private sector. Seventy percent of all nurses work in Port au Prince, where a third of the people in the country live. Outside the capital, most small hospitals have only 1 or 2 qualified nurses. Many of those working in the public sector before the earthquake are now employed by NGOs that have opened clinics or staff hospitals since the earthquake. Many, however, are poorly prepared for these opportunities, having received inadequate initial training.

There are 5 public and 5 more major private nursing schools in Haiti. Together they graduate around 300 qualified nurses per year. The public schools prepare 3-year diploma graduates. These programs were designated to move from a 3-year post-high school level program to a 4-year baccalaureate level prior to the earthquake. Lack of funds, leadership, and expertise at educational reform delayed implementation. The public schools of nursing have upgraded curriculum little in decades and have mainly trained for hospital service. Primary care, public health program management, and patient education had often not been stressed. A private school, the Faculty of Nursing Science of the Episcopal University of Haiti (FSIL), is in Leogane and has strong ties to the University of Michigan. The FSIL of Haiti began a 4-year program in 2005, graduating its first class prior to the earthquake.

Graduates of these programs sit for a national exam as a requirement for registration. The graduate of a 3-year nursing program is a professional, generalist nurse. Specializations in midwifery and HIV care exist, while only informal programs of specialization exist in administration, surgery, and pediatrics. An advanced practice role, similar to a Nurse Practitioner program, does not exist. Yet, in practice, nurses working in private or primary care often do take advanced roles when other practitioners are unavailable (which frequently occurs) and this is a common scenario in many other developing countries.

A culture of updating practice based on new health science knowledge or linking to global health research via the internet has not yet developed. Integration of clinical training with textbook learning has been weak. There are many more unqualified or under-qualified nursing staff trained in some 30 small, unregulated schools. Some of them have a certificate in nursing but are little more than secretaries. Others have long worked outside of health care and need refresher courses or intensive inservice training.

Many nurses, including the country’s nursing leaders, lost their homes or now share them with others because of the earthquake. The National University School of Nursing in Port au Prince (ENIP) was destroyed by the earthquake and most of the second-year students, who were in class that afternoon, were killed. The school reinitiated classes in May 2010, with support in the form of tents donated by UNICEF, psychological counseling provided by the International Medical Corp (IMC), materials provided by Merlin UK, cash support to nurses from International Council of Nurses, as well as assistance and clinical teaching and academic support provided by Columbia University School of Nursing and other schools from North America. The Faculty of Nursing Science of the Episcopal University of Haiti in Leogane was able to reinitiate class in April 2010.

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The Ways Forward 

Reform and refocusing of nursing education and expansion of practice roles in community health and primary care are urgently needed. To do this, Haitian nursing schools need institutional relations with sister schools in other countries. They need the assistance of experienced faculty with international experience to help Haitian schools modernize teaching, develop internet-based learning opportunities, improve primary care clinical rotations, and develop expanded practice roles for nurses in primary care. Establishing the fourth year of training in Haiti’s nursing schools is a vital opportunity to modernize roles and levels within professional nursing and fits with World Health Organization recommendations for nursing development.

To begin addressing the country’s redevelopment needs post-earthquake, the fourth year of nursing training can focus on a nurse practitioner role critical for rural areas. This is consistent with redevelopment of midwifery since the earthquake, with changes including the direct entry of students and plans for midwives to manage births as primary practitioners. Right now, nursing educators would benefit enormously from master’s preparation in education, and hospital administrators need both short and master’s courses.

The MSPP has elaborated a number of plans to reformulate nursing education and practice to better serve the country. These include:

•Rapidly reestablish nursing education for students in their third year of studies at the time of the earthquake to complete their final year of study and graduate.

•Modify curriculum for 1st and 2nd year students in a new ladder system of 4-year professional nursing training.

•Form a community health auxiliary nursing education program to create a ladder system for nursing education, where graduates of baccalaureate programs can study for 1 additional year to become auxiliary nurses ready to work in primary care or to continue on to graduate with a university degree as a professional nurse in 4 years.

•Prioritize selecting students from areas outside the major cities, which will be a major factor influencing their likelihood of returning to those areas to work.

•Create a council of voluntary organizations providing health services in Haiti to participate in training and employment of auxiliary nurses.

•Develop a network of study sites for community health practice among Haitian auxiliary nursing students from the 5 main nursing schools.

•Prepare physicians and nurses working in NGOs to work as preceptors for clinical instruction in their clinics and integrate this into the teaching program.

•Develop and use curricular materials that are modular, can be taught and repeated as necessary until mastered, and that build on capabilities of internet and laptop computer technologies.

•Create a team of international nursing educators to assist existing faculty in the main nursing schools to aid in the development of improved teaching methods.

•Improve coordination among existing schools and strengthen state capacity to regulate training and practice to improve standardization across the country.

•Reflect changes in the scope of nursing practice in improved pre-service accreditation and credentialing.

How these proposals can be translated into action requires nursing engagement in the policy process at a level which has not been seen in the past. Nursing had tended to focus on maintaining quality within the sphere of its limited control, in nursing education. Nursing leaders, at home and abroad, have the opportunity now to develop implementation proposals for the above ideas, engage outside of nursing education to focus on the wider contribution of nursing to health and health systems development, and secure resources from among reconstruction funds to pilot new training and practice models that go beyond traditional hospital-based care. These leaders, including directors of schools in Haiti and nursing staff in the MSPP, need the support and involvement of nurses in NGOs, funding agencies, and collaborating universities in other countries.

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Conclusion 

There is a dearth of examples of success in building a strong health system after a major disaster.11, 12, 13 Haiti nonetheless possesses important assets for the challenges ahead. Large numbers of Haitians have emigrated, gained skills, and provided a stable amount of capital via remittances to their family members. Haiti has attracted many international missions that provided health and education services throughout the country. General educational levels had risen in the last decade, and infant mortality had been cut in half in the last 2 decades.14 The prevalence of HIV/AIDS has been cut from more than 4% to 2.2%.15 This progress demonstrates that large-scale, multiyear recovery and development programs present an unprecedented opportunity for the country.

Haiti is faced with the enormous task of creating a system of care for the majority of people who have long lacked access to basic services. Nursing has much to contribute to this effort. Nurses can rapidly be trained to manage primary care, working with community auxiliaries and serving where physicians are not found. They can be trained more effectively for hospital care, physical and emotional rehabilitation, or for targeted disease programs. Doing so, Haiti will more successfully stabilize rural communities and create a viable economic recovery.

Efforts by the international community to respond to the emergent needs of Haiti after the earthquake were unprecedented. With engaged international support in education, Haitian nursing can transform the health profile of the country. Follow-through now and over the next 8 years, to build education and administration for nursing’s advancement, is needed for the health system to achieve this potential.

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References 

  1. World Health Organization (2008). The global burden of disease: 2004 update. Available online at: http://www.who.int/healthinfo/global_burden_disease/en.http://www.unicef.org/infobycountry/haiti.html. Accessed on June 1, 2010.
  2. World Health Organization (2008). Global Burden of Disease mortality and healthy life expectancy estimates. Available at: http://www.who.int/healthinfo/global_burden_disease/estimates_country/en/index.html. Accessed on April 16, 2010.
  3. Institut Haïtien de l’Enfance et (2001). Publique et de la population. Port au Prince, Haiti: ORC Macro ; 2001.
  4. Anon (2010). Donor nations help Haiti with earthquake reconstruction, debt. The Washington Post. April 4. Available at: http://www.washingtonpost.com/wp-dyn/content/article/2010/04/01/AR2010040103363.html. Accessed on June 28, 2010.
  5. UNICEF (2010). At a glance: Haiti. Available at: http://www.unicef.org/infobycountry/haiti.html. Accessed on February 12, 2010.
  6. Chen L, Evans T, Anand S, Boufford J, Brown L, Chowdhury M, Cueto et al. Human resources for health: overcoming the crisis. The LancetXX;364(9449):1984-90.
  7. Reed G. Cuba answers the call for doctors. Bull World Health Organ. 2010;88:325–326
  8. Ministère de la Santé Ministere De La Sante Publique Et De La Population (2007). Port au Prince: Forum National Pour Le Réalignement De La Réforme Du Secteur Santé En Haïti.
  9. Carl-Ardy Dubois France Brunelle Carine Rousseau (2007). Projet d’Appui au Renforcement des Capacités en gestion de la santé en Haïti. Analyses Et Projection Recensement Des Ressources Humaines En Sante En Haïti.
  10. WHO (2010). Haiti. Available at: http://www.who.int/hac/crises/hti/en. Accessed on March 19, 2008.
  11. Garfield R (2007). Nurses’ Roles in Emergencies. AJA 2007:107:74-5.
  12. Garfield R, Alward NJA. Where are we, and where shall we go in nursing and emergencies?. Prehosp Disaster Med. 2008;23:s9–s10
  13. Garfield R, Chu E. (2010) Building Haiti back better: health sector lessons from the 2004 Indian Ocean tsunami. Humanitarian Exchange Magazine 2010;46:31-3.
  14. Measure DHS. Analysis of data from four Demographic Health Surveys over the last 20 years. Haïti Enquête Mortalité, Morbidité et Utilisation des Services 2005-05. Available from: http://www.measuredhs.com/pubs/pub_details.cfm?ID=666. Accessed on April 15, 2010.
  15. Gaillard EM, Boulos LM, André Cayemittes MP, Eustache L, Van Onacker JD, Duval N, et al. Understanding the reasons for decline of HIV prevalence in Haiti. Sex Transm Infect. 2010;82:14–20

PII: S0029-6554(11)00093-5

doi:10.1016/j.outlook.2011.03.016

Nursing Outlook
Volume 60, Issue 1 , Pages 16-20, January 2012

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